DIRECT INJURY

A physical wound is the most readily recognized form of BRI impacting an individual, which includes physical impact of a bullet creating a visible wound. The majority of bullet injury wounds do not require surgery and are not immediately life-threatening, and are therefore often seen as “minor”. However, due to the tremendous transfer of energy into the tissue creating both a path of injury as well as a perimeter of blast effect, often the most severe components of the injury are not immediately apparent. It is as if a tiny bomb has moved through the tissue, so the more tissue that was touched by the bullet’s energy, the more intense the injury. In addition, superficial “graze” wounds are often seen as completely minor, but have a natural history of severe swelling, drainage, and even skin necrosis that can result in a more symptomatic external wound than one that is associated with a “through and through” injury.

Patients often report significant increase in pain associated with their BRI on the days immediately following the day they were injured. This pain experience is largely mediated by inflammation, muscle spasm, and nerve injury, depending on the length of the bullet path as well as the depth the bullet reaches. Wounds that are associated with fractures are also often extremely painful, even when the fracture does not require surgery.

For this reason it is essential to SCALE the injury to allow for appropriate care and guidance in what to expect after the injury has occurred as neuropathic pain and severe muscle spasm are often far worse experiences symptomatically than the external bullet injury wounds themselves.

A uniquely important part of scaling the wound is addressing whether or not there are retained bullets and fragments. The BRIC defines a retained bullet or fragment as anything greater than 5mm in dimension, or about 1/4 inch. Fragments smaller than this are difficult to locate and remove, but are nonetheless very important. The BRIC defines these as “bullet dust” and recommends careful review of all radiographic images and x-rays to assure that full disclosure is given to patients about the extent and nature of their retained bullets. The most definitive guidance comes from a metanalysis of the literature from Dr. Randi Smith in the Journal of Trauma. Patients with bony fractures or multiple RBF, who are at higher risk of elevated BLL, should be monitored for BLL in intervals of 3 months within the first year of injury. For patients who return with BLL above 5 μg/dL, all efforts must be undertaken to remove fragments if there is no potential to worsen the injury.