Columns, Commentary, Trauma

Stopping the Bleed is Just the Beginning

Issue 5 and Volume 43.

Study suggests that stopping the bleed is just the beginning

Civilian Injuries

Smith ER, Shapiro G, Sarani B. The profile of wounding in civilian public mass shooting fatalities. J Trauma Acute Care Surg. 2016;81(1):86–92.

As news of mass shootings increases in frequency, the streets, malls, schools and workplaces of America sometimes seem like there’s a battlefield in our own backyard. Although this is far from an accurate comparison, injuries occurring during mass shootings do seem to resemble those one might find in war, and recent battlefield experiences have informed the way we care for victims of mass shootings. But are the injury patterns actually the same?

Although strategies aimed at training civilians in bleeding control are valuable, they alone aren’t sufficient.

Methods: This study was a retrospective review of available data from mass shooting events occurring between 1984 and 2013. The researchers attempted to get data from 25 public mass shootings, and they were able to obtain it from 12 events involving 139 patients.

The researchers reviewed all of the cases to determine the anatomical locations of wounds. They were able to review 115 of the cases to determine the anatomical location of the wound that caused death, and reviewed 125 of the cases for the potential for survivability with appropriate prehospital and in-hospital trauma care.

Results: The researchers calculated an average of 2.7 wounds per victim. They noted that “the head and the chest/upper back were the anatomic regions most frequently involved, as 58% of the victims had at least one wound to the head and/or chest/upper back.”

The next most common site of injury was extremity (20%), followed by abdomen/lower back (14%) and by face/neck (9%). Wounds were present in more than one anatomical location for 56% of the victims.

The authors of the study determined that nine of the 125 (7%) victims had injuries that were potentially survivable. The source of the wounds for these patients were a handgun and shotgun, and none of the potentially survivable injuries were caused by a high-velocity rifle.

None of the nine patients had a head wound, nor was an exsanguinating extremity hemorrhage identified. Researchers further identified that medical care supporting the airway and treating chest injury—tension pneumothorax in particular—may be the most effective interventions in reducing mortality in public mass shooting events.

Discussion: Military experiences over the past several years have significantly influenced and advanced civilian trauma care, particularly for injuries caused by violence. The authors identified that civilian mass shooting victims have a different pattern of injury from soldiers injured in combat, resulting in civilian mass shootings being more lethal and presenting less potentially survivable injuries.

The researchers identified civilians being physically closer to the assailant than soldiers in combat situations, and also identified a different injury pattern, because civilians aren’t wearing ballistic armor.

One limitation noted by researchers was that because this study was performed based on autopsy and medical examiner data, we don’t know anything about the injuries of the 176 victims from these 12 events who did survive. It’s possible that some of the survivors had effective extremity bleeding control, which resulted in survival and prevented them from being counted as a fatality.

Conclusion: The authors conclude that although strategies aimed at training civilians in bleeding control are valuable, they alone aren’t sufficient. Public education, they note, “must include strategies to prevent further injury to the wounded, simple airway management, recognition and management of declining respiratory function as a result of penetrating trauma to the chest, proper positioning of the casualty, efficient movement of the casualty, and prevention of hypothermia.”

This research is a charge for EMS to continue to provide public education for response to mass shootings, and provides an evidence base for training beyond bleeding control.