Treatment of gunshot wounds to the groin or axilla are not amenable to a tourniquet since the injury is above the extremity, preventing a tourniquet to be placed above the bleeding site. What makes these injuries even more lethal is that the diameter of the vessel is very large. The conventual wisdom is to would pack these "Junctional Injuries". However the entrance site from 9mm or 5.56 might be small and the underlying wound cavity that needs to be filled, large. So the dilemma is how do you wound pack when you can't fit your finger in the hole.

Typical Size (General Estimate)

• Most entrance wounds are      approximately: 
  • 0.5× to       1.5× the bullet diameter 
• For a 9mm round      (~9 mm / 0.35 in):      
  • Entrance wound is often       about 5–12 mm (≈0.2–0.5 inches) 
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🔹 Why It Varies

The skin is elastic, so it stretches and recoils. This means:

• The wound can appear smaller than      the bullet 
• Or occasionally larger/irregular   

🔹 Factors That Affect Diameter

1. Bullet characteristics

• Caliber (size) 
• Shape (round nose vs hollow      point vs flat tip) 
• Deformation (mushrooming      usually happens after entry) 

2. Velocity

• Higher velocity → more tissue      disruption → potentially larger/irregular wound 

3. Distance

• Close range: may see burning,      soot, stippling,      but size may not change much 
• Contact wounds can appear larger or      stellate due to      gas expansion 

4. Angle of entry

• Perpendicular → more circular      
• Oblique → oval or      slit-like 

5. Body location

• Skin tension (Langer’s lines)      
• Areas over bone vs soft      tissue

You are not packing the “hole” — you are packing the BLEED

• Many GSW entrance wounds are:      
  • Small 
  • Narrow tract 
  • Not easily packable 

👉 If you can’t reach the bleeding source, packing won’t work.

⚠️ Common Mistakes (Great for your “misses” slide)

• Packing only the      surface 
• Not going deep enough 
• Stopping when resistance is      felt too early 
• Not holding pressure long      enough 
• Trying to pack non-compressible      areas (chest/abdomen)

🔴 When it is too small (rare but real)

You may not be able to pack effectively if:

• Wound is truly      superficial 
• No identifiable tract 
• Bleeding is diffuse, not      focal 
• Patient body habitus limits      access 

👉 In those cases:

• Direct      pressure 
• Consider junctional      tourniquet device     (if available) 
• Rapid evacuation 

 🔶 Critical Teaching Point 

👉 “If it’s bleeding and you can get a finger in it — you can pack it.”

• Don’t be fooled by a small      entrance wound 
• The decision is based on: 
  • Bleeding       severity 
  • Anatomic       location (compressible vs non-compressible)