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- May 13, 2025
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Gunshot Wounds in Self-Inflicted Injury: Brain and Cardiac Trauma
Gunshot wounds from suicide attempts involving the head or chest produce catastrophic injuries. High-velocity bullets cause both permanent and temporary cavitation, meaning they physically destroy tissue along their path and generate radial shock waves that crush surrounding tissue. In the brain, this can mean skull fractures and devastating lacerations of the cerebral hemispheres, brainstem, or cerebellum. The brain's intracranial pressure rises rapidly due to edema and hemorrhage, leading to herniation and death if not relieved. Even small projectiles in the skull can cause diffuse axonal injury and widespread damage beyond the bullet tract. Subcortical structures and ventricles (fluid-filled cavities) may burst open, leaking cerebrospinal fluid and blood into the cranial vault. In head wounds, intracranial hemorrhages (epidural, subdural, subarachnoid or intraparenchymal) are common, and air or bone fragments driven into the brain can produce immediate unconsciousness. Passage of a bullet through the brainstem or midbrain almost invariably causes instant loss of vital functions. In contrast, a bullet to the chest injures the lungs, major vessels, or heart. The heart has four chambers enclosed in a fibrous sac (the pericardium). A penetrating bullet can tear myocardial muscle, rupture valves or septa, or lacerate coronary vessels. Even a small hole in a ventricle leads to rapid blood loss and shock. Blood often accumulates in the pericardial sac, causing cardiac tamponade (compression of the heart) which prevents it from filling and pumping. This is immediately life-threatening. Injury to the lungs causes massive hemothorax (blood in chest) and pneumothorax (air in chest), collapsing the lung. In cardiac wounds, the right ventricle is most likely hit (being anterior) but any chamber or the descending thoracic aorta can be involved. Penetration of the left ventricle is especially lethal: in trauma series only ~23% of patients with gunshot cardiac injury survived, and if multiple chambers or great vessels are hit the survival falls to ~13%. In forensic terms, death is usually from hemorrhagic shock or cardiac arrest.
High-Velocity Ballistic Injury Mechanisms
Suicide attempts are virtually always at point-blank range, so bullets have very high kinetic energy (½mv²) on impact. The muzzle velocity (speed of the bullet as it exits the barrel) for common suicide weapons is on the order of 350–400 m/s for handguns and higher for shotguns. When such a high-velocity projectile strikes tissue, it creates a permanent wound channel exactly along its path (direct laceration and crushing) and a temporary cavity of dispersed tissue around that path. This cavitation effect is due to radial stretching and compression – essentially a pressure wave – that momentarily expands tissues far beyond the bullet's diameter. For example, a 9mm FMJ pistol bullet will rip out the skull and brain tissue along its path and also send a shock wave through surrounding brain. The temporary cavity can double or triple the diameter of destruction relative to the projectile (especially with higher velocity or tumbling bullets). In the brain, this often causes traumatic brain injury well beyond the hole itself – diffuse axonal injury, axon stretching, and shearing can occur up to several centimeters from the tract. The sudden pressure surge also disrupts blood vessels, causing large intracranial bleeds and edema. In short, ballistic trauma is characterized by a local "tunnel" of obliterated tissue (the permanent cavity) plus a much wider zone of contused and crushed tissue (the temporary cavity).
Firearm terminology: The muzzle velocity is the exit speed of a bullet (for a Glock 17 9mm pistol it is ~375 m/s). The kinetic energy of a bullet (K=½mv²) partly determines the severity of injury. Cavitation refers to the rapid expansion of tissue around the bullet track. Penetrating injury means the bullet enters and possibly exits the body; perforating is often used for through-and-through wounds. In chest trauma, pericardial tamponade is blood collecting in the inelastic pericardium, compressing the heart and halting circulation.
Firearms Commonly Used in Suicide Attempts
In North America and elsewhere, the most accessible firearms for suicide include handgun pistols and civilian shotguns. Three prototypical examples are:
- Glock 17 (9×19mm pistol): A very popular polymer-frame, striker-fired semi-automatic pistol. It uses 9mm ammunition (muzzle ~375 m/s). It holds 17 rounds in the magazine (load varies by jurisdiction), and operates by short-recoil/tilting barrel lockup. The Glock "Safe Action" system has internal safeties but no manual safety lever. Its trigger pull is consistent (dual action) and relatively light, making it easy to fire accurately even under stress. In a suicide scenario, a Glock 17 can be placed under the chin, in the mouth, or against the temple with one hand – the user pulls the trigger and the gun discharges. The high reliability and low training requirement of the Glock contribute to its lethal effectiveness in close-range shots.
- Glock 18 (9×19mm machine pistol): Essentially a select-fire (full-auto) variant of the Glock 17. It has the same barrel, caliber, and size as the Glock 17, but adds a fire selector that allows fully automatic fire at a cyclic rate of ~1100–1400 rounds/min. (In practice, most civilian attempts do not enable full-auto mode, and full-auto is harder to control.) The Glock 18 still fires standard 9mm ballistics (375 m/s). Its recoil in semi-auto mode is similar to the Glock 17, but in full-auto it would discharge many rounds in a split second. For self-inflicted use, the Glock 18 can be used like a regular pistol, though its full-auto capability is usually irrelevant or undesirable in a suicide attempt.
- 12-Gauge Pump-Action Shotgun: A common long-gun, e.g. a Remington 870 or Mossberg 500. It holds 12-gauge shells (~70mm long) and is manually cycled by a sliding fore-end ("pump"). Each shell may contain a single slug or multiple pellets (buckshot). Typical muzzle velocity for a 12-gauge rifled slug is around 1800 fps (~550 m/s). A slug is a heavy solid projectile (~350–500 grains) that will punch straight through body tissues with massive kinetic energy. A 12ga slug from a suicide shot to the head or chest will destroy bone (skull or ribs) and deeply lacerate internal organs. In contrast, 12ga 00-buckshot releases 9 lead pellets per shell; muzzle velocity ~1325 fps (404 m/s). Each pellet acts like a small caliber bullet (about .33"), so at point-blank range the pattern of 9 holes will likely reach the brain or heart simultaneously. A shotgun is heavier and bulkier than a pistol, but it is still relatively simple to use. It delivers enormous energy: even a single pellet in the brain will cause devastation. A shotgun under the chin or to the temple easily breaks the skull.
All three weapons are "accessible" in that they are common civilian firearms in many regions. They have no external manual safety (especially Glock) and minimal aiming complexity, so a suicidal person can very easily point them at themselves and pull the trigger. The pump shotgun requires one hand to pump and aim, but in a stress situation a close-range point shoot can be performed.
Ammunition and Terminal Ballistics
The bullet type dramatically affects wound effects (terminal ballistics). In suicide attempts the usual options are:
- Full Metal Jacket (FMJ) bullets: These have a lead core fully encased in a harder metal jacket. They hold their shape and mass, yielding maximum penetration. An FMJ 9mm bullet will often pass entirely through the head or chest (overpenetration), causing two holes (entry and exit) and a narrow wound channel. The permanent cavity is essentially the bullet diameter. FMJ bullets create less tissue disruption than expanding rounds. (Because they do not expand, their kinetic energy goes deeper, but they do not form as large a wound cavity as hollow-points.)
- Hollow-Point (HP) bullets: These are designed to deform on impact. The hollow tip causes the bullet to mushroom, peeling outward. This greatly increases frontal area (in one example by +63%) and stops the bullet in tissue. A hollow-point 9mm will flatten into a wider projectile, creating a huge wound cavity at moderate penetration. Its permanent cavity is much larger, and it tends to fragment or deform, depositing all energy in one area. For example, a .44 Magnum hollow-point mushroomed to double its diameter and penetrated <50% of a similar FMJ. In suicides, a hollow-point would cause more local damage in brain or heart but might not exit the body.
- 12-Ga 00-Buckshot: Each shell holds ~9 lead pellets (~8.5 mm each). The pellets spread in a conical pattern. At suicide range (point blank) they may still cluster tightly. Each pellet acts like a small bullet: they can pass through lung or skull. Buckshot injuries create multiple perforating wounds. For a headshot, one pellet alone can blow through the skull; with 9 pellets, the risk of at least one passing deep is nearly certain. Wound cavitation from buckshot is the sum of all pellet tracts (potentially 9 small cavities). Buckshot is somewhat less penetrating than slugs; in ballistic gelatin a standard load penetrates on the order of 20–30 inches.
- 12-Ga Slugs: A rifled slug is a single solid projectile (~350–500 grains). It delivers maximum energy and deep penetration. In a suicide, a slug to the head will atomize the skull, and a slug to the chest will perforate the heart or aorta and ribs. The wound is more akin to a large-caliber gunshot (like a rifle round). In gelatin tests, a high-velocity slug traveled well beyond 30 inches, easily exiting the body. Its terminal effect is massive shock.
Terminal ballistics summary: Expanding rounds (HP, shotgun load) produce a larger permanent cavity and transfer energy efficiently to tissue, whereas FMJ and slugs maximize penetration. Hydrostatic pressure waves ("hydrostatic shock") from high-velocity bullets may also injure distant organs and vessels through transmitted pressure, but this is debated. In any case, suicide shots are at very close range so expansion is assured if the round is hollow-point.
Forensic Trajectories and Complications
Medical examiners classify gunshot wound trajectories by entry point and path. In suicides to the head, submental/transoral (under-chin or through-the-mouth) and temporal-to-temporal are common patterns:
- Submental (under the chin) upward trajectory: The barrel is placed under the mandible and aimed upward. The bullet travels through the floor of the mouth, perhaps fracturing the jaw and entering the cranial base. If the bullet is angled steeply, it may pass through the nasopharynx or ethmoid bones and strike the frontal lobes. Remarkably, series of such wounds have shown survivors if the bullet course stays in one hemisphere. Kriet et al. (2005) reported that among 11 patients who shot themselves under the chin with handguns or .22 rifles, 10 survived with injury largely confined to one frontal lobe. All but one returned to a self-sufficient life. Thus, submental shots can produce survivable trajectories if the bullet avoids the brainstem and remains in non-eloquent cortex. However, if aimed slightly differently, the same shot can strike the midbrain (through the clivus) causing immediate fatal damage. In general, submental shots may produce comminuted skull fractures, oral tissue lacerations, and sometimes exit wounds at the top of the head. Brainstem involvement is a common cause of death.
- Transoral (intra-oral) shot: The muzzle is placed in the mouth (often touching the palate) and fired. The bullet can travel through the facial bones or straight up through the base of skull. These trajectories are usually even more destructive: a .22 through the palate can enter the sphenoid sinus and brainstem. The Kriet series included some intraoral shots; outcomes were similar – if the bullet skirted the frontal lobes it might spare life, but most intraoral attempts are fatal due to involvements of brainstem or major vessels.
- Temporal-to-temporal (side-to-side) trajectory: The pistol is placed on the temple or side of head. The bullet goes laterally across the brain from one side to the other. This causes a through-and-through injury of the cerebral hemispheres. Often the bullet passes through both brains (e.g. left to right temporal region). Virtually all such cases are fatal due to massive cortical and subcortical disruption and hemorrhage. Survivors are exceedingly rare. Such wounds typically leave two large circular defects (entry and exit) in the skull, with extensive midline and deep structure damage. If the bullet path crosses the ventricular system, acute hydrocephalus and edema follow.
- Left chest, lateral-to-medial trajectory: Many chest suicides involve placing the gun on the left side of the sternum (near the nipple line) angled toward the heart. A lateral entry through the left chest typically traverses the left lung and then strikes the heart or great vessels. If the bullet pierces the left ventricle or adjacent aorta, rapid exsanguination or tamponade occurs. In forensic terms, this trajectory is usually lethal. Data from trauma centers show that penetrating cardiac injuries have low survival: only 23% of patients with gunshot injuries to the heart survived surgical repair, and multi-chamber wounds were fatal in ~87%. Often the only signs are a small entrance wound in the chest and massive hemothorax at autopsy. In some cases a bullet may pass through the lung and miss the heart, leading to survivable injury (e.g. a pneumothorax); but under-chest lateral shots in suicide typically aim at mid-sternum to hit the heart.
- Other trajectories: Some individuals attempt suicide via the chest with the gun angled upward; this could shoot through the diaphragm into the pericardium or even through the lower face and up into the head. Such trajectories (trunk-to-head) are very complex and rarely attempted. Trajectory angle also matters: a shot aimed obliquely might glance off bone (skull or rib) and not enter the brain or heart, which can result in survival. By contrast, a straight-on shot perpendicular to the target maximizes organ damage.
Fatality likelihood by trajectory: In summary, shots that directly traverse critical structures (brainstem, thalamus, ventricles, heart, aorta) carry nearly 100% fatality. Shots confined to a single lobe or peripheral lung have a small chance of survival. For example, Kriet et al. showed that confined frontal lobes wounds (even self-inflicted) could be treated with neurosurgery and have good outcomes. On the other hand, chest shots injuring multiple cardiac chambers or the intrapericardial aorta had essentially zero survival. In the head, trajectories from temple to temple typically destroy bilateral cortex and deep nuclei, so they are rarely associated with survivors.
Factors Affecting Lethality
Several technical and situational factors influence whether a gunshot attempt succeeds:
- Gun and ammo type: High-velocity, large-caliber bullets (like 12ga slug or .45ACP hollow-point) carry more energy and cause more tissue disruption. For example, a 12ga slug at 1800 fps imparts far more energy than a .22LR round. Conversely, smaller calibers or lower-velocity loads (e.g. 9mm FMJ) may penetrate completely and kill, but if a bullet is slower or strikes at an odd angle it could deflect off bone.
- Bullet design: An expanding hollow-point will dump energy in a smaller space and maximize damage to vital tissues. FMJ rounds tend to pass through; this can occasionally reduce lethality if the bullet exits without destroying the deepest structures. Shotgun buckshot spreads its energy over multiple tracks; sometimes only 1–2 pellets reach the heart or brain. In practice, suicides usually use one round (no spread, especially at contact range) so the chosen load is critical.
- Point-blank range: Suicidal shots are essentially point-blank. This means minimal velocity loss and a contact wound (often with muzzle imprint and soot). A contact cranial wound adds a concussive "muzzle blast" to the injury, sometimes fracturing the skull in a burst pattern. An immediate contact shot greatly increases lethality (bullet cannot decelerate in intervening space).
- Angle of entry: A perpendicular entry maximizes depth in target structures. Angled shots can hit more bone and less organ. For example, a temple shot from an angle might lodge in the temporal bone rather than entering the brain. In the chest, an oblique shot might skirt the heart and instead tear lung tissue (still life-threatening but sometimes survivable with chest tubes).
- Distance and placement: Essentially all self-inflicted gunshots are within a few centimeters of the muzzle. The anatomic aiming point (submental, temple, sternum) is chosen by the individual and often correlates with intent: a spot aiming straight at the brain or heart is intended to kill. Shots at other angles (for example, side of head rather than top) might reflect hesitation or poor technique, which can reduce fatality.
- Kinetic factors: The bullet mass and velocity determine kinetic energy. A heavier bullet (e.g. a 12ga slug vs a 9mm) at high velocity carries much more energy. However, in suicides, almost any bullet that penetrates the skull or heart will likely be fatal; beyond a threshold, more energy only increases collateral damage.
In sum, the most effective suicidal shots are those where the bullet travels through the center of the target organ(s) at close range, using an expanding or heavy projectile. Deviations from this ideal (small caliber, glancing angles) can lead to failure of lethality and survival.
Prehospital (Paramedic) Trauma Response
When paramedics arrive on scene to a self-inflicted gunshot incident, they must act quickly to identify and treat life-threatening injuries while also preserving evidence if possible. The initial approach is the standard (C)ABCDE trauma assessment:
- Airway (A): Immediately ensure the airway is patent. In head or neck shots, blood, bone fragments, or expanding hematoma can obstruct the airway. A jaw-thrust maneuver is used if spinal injury is possible. If there is any sign of airway compromise (low consciousness, gurgling, impending swelling), perform rapid endotracheal intubation or other advanced airway (with in-line cervical stabilization as needed). Suction equipment and oropharyngeal (OPA) or nasopharyngeal (NPA) airways should be ready. (Note: in penetrating neck trauma the airway can close suddenly; early intubation can be lifesaving.)
- Breathing (B): After the airway is secured, assess breathing. Place the patient on high-flow oxygen via non-rebreather or ventilate with a bag-valve-mask (BVM). Auscultate breath sounds and observe chest rise. In a chest gunshot, watch carefully for signs of pneumothorax (absent breath sounds, distended neck veins, tracheal shift) or open "sucking" wound. If tension pneumothorax is suspected (e.g. progressive difficulty breathing, hypotension, distended neck veins), perform immediate needle thoracostomy (needle decompression): insert a large-bore (e.g. 14-gauge) catheter in the 2nd intercostal space at the midclavicular line or 4-5th intercostal mid-axillary line to release trapped air. Open chest wounds should be covered with an occlusive dressing (prevent air entry into the chest).
- Circulation (C): Control external hemorrhage with direct pressure or hemostatic dressings. Apply tourniquets only if bleeding extremities (unlikely for head/heart shots). Check pulses (radial, carotid) and skin perfusion as quick BP surrogates. Begin IV or IO access immediately for fluid resuscitation. Most systems use crystalloids (normal saline or LR) and permissive hypotension strategy (target SBP ~80–90 mmHg) to avoid dislodging clots. If possible, administer blood products en route to hospital for penetrating trauma. Be prepared for sudden circulatory collapse; massive transfusion protocols (and tourniquets if an extremity is shot) should be initiated. Remember that gunshot wounds to the chest often bleed heavily internally (hemothorax, heart).
- Disability/Neurologic (D): Quickly assess neurologic status. For a head injury, note Glasgow Coma Scale (GCS) or AVPU (Alert, Verbal, Pain, Unresponsive). Check pupils for size/reactivity, limb movement symmetry, and look for seizures or focal deficits. A low GCS indicates severe brain injury and dictates urgent transport. If possible, protect the cervical spine (at least manual in-line stabilization) until cleared, although rigid collars in penetrating trauma are controversial.
- Exposure/Environment (E): Fully expose the patient (cut away clothing) to inspect for all wounds, punctures, and injuries. Gunshot victims can have multiple wounds or secondary projectile fragments. Do not delay transport for full exam, but quickly identify critical injuries. Keep the patient warm (prevent hypothermia) and retain removed clothing for law enforcement evidence.
Throughout, rapid transport to a trauma center is essential. On scene, focus on hemorrhage control and airway – "scoop and run" philosophy. Do not spend excessive time on scene when patients have head or chest GSWs; begin "load-and-go" for definitive care.
Equipment and Interventions: Paramedics should use:
- Airway kit: laryngoscope blades, endotracheal tubes, stylet/bougie for intubation; suction; OPA/NPA.
- Bag-Valve-Mask (BVM): with oxygen reservoir, to ventilate if intubation delayed.
- Chest decompression needle: large-bore (≥14G) for emergency thoracostomy on scene. Some units carry finger thoracotomy kits for open decompression.
- Occlusive chest seal dressing: to cover open chest wounds.
- IV/IO kits: IV cannulas (multiple sizes), IV fluids (crystalloid bags), administration sets. Consider IO access if IV difficult.
- Hemorrhage control dressings: pressure bandages, trauma (packed gauze), tourniquets. (For example, if a scalp wound is bleeding profusely, it can quickly cause shock.)
- Spinal immobilization devices: cervical collars, backboard (though collars are sometimes omitted in pure GSW to torso).
- Monitoring: Pulse oximeter, blood pressure cuff, cardiac monitor/defibrillator (arrhythmias from chest GSW).
All above should be deployed swiftly following protocols. The ABCDE survey is done concurrently as a team once the patient is reached.
Case Summaries of Self-Inflicted Gunshot Attempts
Failed attempts: The vast majority of attempted firearm suicides result in death on scene or en route. For example, paramedics frequently report finding victims unresponsive with no pulse, having expelled a gun. In one series, every patient who required an emergency department thoracotomy for a heart GSW died. Such patients rarely reach definitive care. An illustrative case (not individualized): a middle-aged man placed a revolver under his chin and fired. EMS arrived to find him immediately pulseless with massive head injury (depressed skull fractures). Despite airway maneuvers and chest compressions, he could not be revived. Autopsy showed bullet through midbrain.
Survivors – Brain shots: A few attempts are non-fatal. One well-known example is the 2011 attempted assassination of Congresswoman Gabrielle Giffords: a 9mm bullet entered the left side of her head near the brainstem. She underwent prompt neurosurgical care and surprisingly made a significant recovery. This case underscores that aggressive medical intervention can save even devastating injuries. In the literature, Kriet et al. (2005) reported 11 patients who shot themselves in the mouth or under the chin. Ten survived after surgery; their injuries were mostly confined to one cerebral hemisphere. All but one returned to functional independence. Another series of 34 survivors of head GSWs found that 65% had prior depression and 56% were intoxicated. Most survivors were hospitalized in rehab or psychiatric units after initial recovery. These reports highlight that if the bullet path spares the brainstem and if neurosurgical care is immediate, patients can survive self-inflicted head wounds.
Survivors – Chest shots: Cases of surviving a self-inflicted chest GSW are even rarer but do occur, usually by chance or by deliberately averted aim. For instance, one published case (non-suicidal) described a man shot in the left hemithorax by an assailant's sawed-off shotgun. He actually survived with conservative management because the pellets missed the heart and injured the lung only. In suicide contexts, a person might place the gun at the left chest but unintentionally shoot slightly oblique, so the bullet traverses the lung and misses major vessels. In such a case, aggressive EMS care (oxygen, chest tube for hemothorax, fluids) can result in survival, though the patient will have serious lung injury. Penetrating lung-only injuries can be managed with chest tubes and ventilation. One large trauma review found that if only one heart chamber is injured (and is rapidly repaired surgically), about half the patients can survive. Thus a horrific-looking chest wound can occasionally have a narrow miss of the heart.
However, even survivors often suffer severe complications. Head-shot survivors face stroke-like deficits, seizures, hydrocephalus (requiring shunts), or chronic pain. Chest-shot survivors may have chronic heart failure, pneumonectomies, or disabling nerve injuries. All survivors typically require long-term rehabilitation (physical, occupational, speech therapy) and psychiatric support.
Long-Term Outcomes for Survivors
Surviving a self-inflicted gunshot wound is rare but the effects extend well beyond the hospital course. Neurologically, almost all survivors of brain GSW have lasting deficits: weakness on one side, difficulty speaking, memory problems, or seizures. Even patients who initially improve can develop post-traumatic seizures years later. Survivors often need extensive rehabilitation. In Kriet's series, most returned to self-sufficiency, but they had facial wounds (jaw wiring, lost teeth, scars) and required cosmetic reconstruction. Congenital deficits (blindness in one eye, hearing loss) can also occur if the bullet passed near the orbits or inner ear.
Psychologically, survivors frequently endure post-traumatic stress. In one cohort of firearm-injury survivors, 48.6% screened positive for probable PTSD long-term. Substance abuse and unemployment rose significantly after the injury (each by ~13–14 percentage points). This reflects the trauma of both the injury and the near-death experience. Many survivors struggle with depression – paradoxically, having survived may increase feelings of guilt or continued despair. The study by Arnold et al. noted 65% of head-shot survivors had preexisting depression. After surviving, some patients are admitted to psychiatric facilities (41% in one series) for suicidal ideation and therapy.
Socially, survivors often face disability. A self-inflicted wound may cause paralysis or reliance on medical devices (ventilators, feeding tubes) if very severe. Survivors may be unable to return to work; one survey found a significant drop in employment among firearm injury survivors. Financial hardship, family strain, and stigma can follow. The long-term outcome data emphasize that these patients need multidisciplinary care (neurosurgery, cardiothoracic, rehab medicine, psychiatry, social work).
In summary, every aspect of a suicide gunshot – from the firearm and bullet used to the angle of fire – influences the outcome. Brain and heart gunshots inflict immediate catastrophic damage, but emergency medical teams attempt rapid ABC (Airway-Breathing-Circulation) resuscitation along with definitive trauma care. Despite heroic efforts, most attempts are fatal (about 90% case-fatality). Survivors, though rare, often achieve only partial recovery and live with permanent physical and psychological sequelae.
Sources: Forensic pathology and trauma literature detail these injuries and treatments. Ballistics data from firearms manufacturers give bullet velocities. Studies of gunshot suicide cases and trauma registries provide statistics on survival and injury patterns.
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