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Ballistic Injuries In The Emergency Department - $30.00
December 2011 (Volume 13, Number 12)
This issue includes 4 AMA PRA Category 1 CreditsTM, 4 ACEP Category 1 credits, 4 AAFP Prescribed credits, and 4 AOA Category 2A or 2B CME credits.
David Bruner, MD, FAAEM
Assistant Program Director, Emergency Medicine Department, Naval Medical Research Center, Portsmouth, VA
Corey G. Gustafson, DO
Staff Emergency Physician, Naval Hospital Camp Pendleton, Camp Pendleton, CA
Catherine Visintainer, MD, FACEP
Academic Faculty, Naval Medical Center Portsmouth, Portsmouth, VA
Keith A. Marill, MD
Assistant Professor, Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
Matthew J. Walsh, MD
Associate Professor, Department of Emergency Medicine, University of New Mexico, Albuquerque, NM
According to 2007 data, gunshot wounds from homicides, suicides, and accidents caused 31,000 deaths in the United States, with even higher numbers of serious, nonfatal injuries. In recent years, new evidence on effective treatment of patients with gunshot wounds has come from military settings and is being adapted for civilian emergency departments (EDs). Effective, evidence-based management of ballistic injuries in the ED is vital. This issue reviews the physics of ballistics as it relates to the tracts and patterns of tissue injury caused by different types of firearms and missiles, and it takes a regional approach to reviewing the current evidence for managing gunshot wounds to the head, neck, thorax, abdomen, genitourinary (GU) system, extremities, and soft tissues. Current guidelines as well as new research and evidence regarding fluid resuscitation, airway management, evaluation strategies, drug therapies, and documentation are discussed.
Excerpt From This Issue
A 25-year-old man presents to the ED via ambulance after sustaining a single gunshot wound to the upper abdomen. There is no apparent exit wound. He is awake, in obvious pain and distress, with labored spontaneous breathing. He was reportedly shot with a handgun at close range, and there was significant blood loss at the scene. He has decreased breath sounds on the left side and a mildly tender abdomen with a small wound over the left anterior lower chest. A FAST examination shows no free fluid in the abdomen and no pericardial effusion. A left-sided chest tube is placed, with 200 mL of blood out immediately, and subsequent chest x-ray shows a right hemothorax with a bullet lodged in the left lower lobe. You contact the trauma surgeon, who asks if you think the bullet traversed the diaphragm and if additional tests are needed before he arrives for surgery.
An 18-year-old man presents after being accidentally shot in the left leg with a shotgun while hunting with his family. He has multiple small- and medium-size wounds in his left thigh and lower leg. He is in excruciating pain, but he has good distal pulses, has an intact neurologic examination of that extremity, and is otherwise hemodynamically stable. An x-ray shows multiple metal fragments within the leg and midshaft fractures of the tibia and fibula. As you treat his pain and address the wounds, you wonder about the need for further vascular studies.
A 38-year-old man who was shot in the head is brought in by EMS with a laryngotracheal airway in place. He has a GCS score of 5 on arrival. His vital signs are normal except for a pulse of 115 beat per minute; his oxygen saturation is 94% via the airway. There appears to be only 1 wound and no other injuries elsewhere on his body. Before you send him to the CT scanner, you prepare to establish a definitive airway, but you wonder about the right drugs and ventilator strategy to help control his intracranial pressure.