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Tuesday, July 29, 2014
Handling A Gunshot Wound
A few months ago, my wife who was being treated for postpartum depression took my sidearm out of the safe and shot herself under the chin. I was by her side within 15 seconds, where she lay on her back still very much alive. But she died despite my efforts to clear her airway and stop the bleeding. After reading the ME`s report, I was very disturbed to find that the wound path was very far forward and the round never entered the cranial vault - despite an exit wound exactly in the middle of her forehead. Upon seeing this wound, I thought there was no hope but tried anyway. However, the cause of death was blood loss and/or asphyxia from blood and tissue she aspirated, not brain trauma, as I suspected.
I have some very basic training in gunshot wounds as a result of time associated with the military, but was unable to do anything. The wound path perforated her trachea exactly in the center and just above the voice box (fracturing her jaw in several places by the force of the muzzle flash), shattering her tongue, and severing her lingual artery. It continued up through the roof of her mouth and out, apparently skipping along her sinus.
What upsets me most about all of this is that I didn’t have the presence of mind to turn her on her side/stomach so she wouldn’t aspirate the blood – don’t know what I was thinking. My question to you is would this have (even theoretically) made any difference in the outcome? I wonder often if I had been able to secure her airway until the EMTs got there (about 8 minutes) if she could have been saved, or if the blood loss would have been too massive.
Any insight into this would be greatly appreciated. Also, please know that there is no need to spare my feelings. Quite the opposite, I want and need to know the objective truth, if it is possible for you to help me find it.
Thank you very, very much for your time and consideration.
Regrettably there was most likely nothing you could have done to save your wife. Turning her head to the side or placing her on her stomach would not have helped because there were two problems, number one bleeding into her airway from an injury to the lingual artery (blood supply to the tongue) would have been at too rapid a rate to keep her airway clear without the aid of a suction apparatus. The second factor would be progessively increasing swelling of her upper airway which is the body's normal response to injury and would have been compounded by hematoma or a blood clot accumulating within the tissue causing the same effect as swelling or edema. These two events would have caused progressive narrowing and ultimately closure of her airway, resulting in asphyxia.
Under ideal circumstances such an injury would require early intubation to secure the airway and that would have been extremely difficult with blood obscuring visibility and an unstable mandible. With an injury to the trachea there would be the concern of placing the endotracheal tube below the level of the injury in order to ventilate the lungs and being careful that the tube did not go through the wound exiting the trachea completely.
Often in these situations visualization of the upper airway and the vocal cords are extremely difficult because of the blood and swelling requiring what is called the creation of a surgical airway or crichothyrotomy. This is similar to a tracheostomy, but performed higher up on the neck just below the larynx (voice box) through the cricothyroid membrane. The airway is closer to the skin level at this point and can be more rapidly accessed at this level. A large diameter intravenous catheter can also be inserted into the airway at this site as a temporary measure. This procedure is generally done by someone with surgical training and a knowledge of the anatomy of this area.
Kenneth Davis, Jr, MD, FACS
Professor of Surgery and Clinical Anesthesia
College of Medicine
University of Cincinnati