Case of the Month
July 2009

12-year-old male – BB gun injury

Dispatch

Your aid unit is dispatched to a third hand report of a 12-year-old male with a BB gun injury.

While en route the dispatcher notifies you that the reporting party was sent to request aid, but does not know the location of the injury on the patient. The dispatcher advises you the patient is being transported to the dispatch location on an ATV as the incident occurred five miles into the woods.

En route your crew discusses the following considerations:

• Potential trauma caused by BB guns
• Pediatric SICK/NOT SICK assessment (Pediatric Triangle)
• Transport destination

Scene Size-up
Your aid unit arrives at the trail head in a rural, forested area. After a few minutes you see an ATV approaching. You see a boy, without a shirt, sitting in the passenger seat—he is leaning against the driver.

Initial Assessment
As you approach the patient you see he is ashen and breathing rapidly. Touching his skin you feel it is cool and clammy. You notice a small, red spot on his chest a couple of inches above the left nipple. It appears to be a small penetrating injury. The patient seems weak and somewhat lethargic. The Pediatric Triangle (appearance, work of breathing, circulation to the skin) indicates the SICK category.

Initial Treatment
You immediately cover the injury site with a gloved hand and your team prepares a three-sided occlusive dressing. You move the patient to a stretcher and place him in the semi-Fowler’s position while your partner administers high flow oxygen. You examine his back for an exit wound and find none. Vitals are taken and you request an ALS unit for further evaluation and treatment. Due to the patient’s condition you elect to transport immediately and rendezvous with the ALS unit en route to the hospital.

Pediatric Assessment Triangle

• Appearance                Lethargic but aware of person, place, and time
• Work of Breathing        Respirations 44, diaphoretic
• Circulation to Skin        Ashen, cool clammy skin; radial pulse weak but regular, 136
• Blood pressure             74/P
• Pulse oximetry             92% on room air

Further Evaluation and Treatment
A quick interview with the patient’s father, who drove the ATV, reveals the patient was struck by a BB from a high power air rifle from a distance of 20 feet. The injury was unintentional – a group of boys was having a BB-gun fight and it got out of hand. The father assures you the patient was hit once only. 

After initiation of high flow oxygen the patient’s appearance and breathing improve; his level of consciousness improves somewhat and his breathing efforts improve; however, his skin color still is poor and he is mildly diaphoretic. 

A full trauma exam finds no other injuries and SAMPLE questions produce no other causes for concern.    His blood pressure is now 84/P with a heart rate of 110. When released to the ALS unit an IV line is placed and transport continues to a local trauma center. 

At the hospital the emergency staff determines that a BB has penetrated the pericardial sac. Imaging reveals a mild pericardial tamponade and a moderate cardiac contusion. A cardiac surgeon is consulted to remove the object. Over the course of several days the patient improves and is discharged from the hospital.

BB and Pellet Gun Injuries
Approximately 30,000 people are treated in emergency departments each year for BB and pellet gun injuries. The overwhelming majority are minors (81% are 19 years of age or less with the injury peak occurring with 10- to 14-year-old males). Although relatively non-lethal, non-powder guns result in 4 to 5 deaths annually in the United States.

At close range, BB and pellet guns can inflict tissue damage similar to that of bullets fired from low velocity conventional firearms. Unfortunately BB and pellet weapons are often viewed as toys used by youngsters and so many of the victims are young. Interestingly enough 63% of all recreational perforating eye injuries are caused by these weapons–lending truth to the saying ”You’ll put your eye out!”

Treatment for wounds inflicted by non-powder guns is similar to that for any penetrating weapon.  Probably the most important caveat is to not underestimate the potential for these injuries.

A BB is a .177 caliber projectile and weighs around 5.1 grains. Lead .177 caliber pellets vary in weight between 7 and 9.5 grains. For comparison, a .22 caliber long rifle bullet typically weighs between 30 and 40 grams and travels at 1080 to 1750 feet per second (FPS). An M16 round is a .223 caliber bullet weighing about 62 grains that travels about 3100 FPS.

Air Rifles (.177 caliber BB or pellet)
Daisy Red Ryder                                    280 FPS
Crossman 760                                       650 FPS
Beeman RS1 Combo                               1000 FPS
Benjamin Sheridan Super Streak               1500 FPS

Air Pistols (.177 caliber BB or pellet)
Beeman 2004 Deluxe                             410 FPS
Daisy BB Gun Pistol CO2                        480 FPS
Benjamin Air Pistol Pump Pellet               525 FPS
Crossman 1377 Pump Pellet Pistol           600 FPS

Injury risk of non-powder guns
American Academy of Pediatrics (external Web site)

A case of a BB-gun pellet injury
The Free Library (external Web site)