An Evidence-Based Approach to Managing Gunshot Wounds in the Emergency Department (Trauma CME)

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Delivery Method:	Online
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Publication Date: April 2023 (Volume 25, Number 4)

CME Credits: 4 AMA PRA Category 1 Credits™, 4 ACEP Category I credits, 4 AAFP Prescribed credits, and 4 AOA Category 2-A or 2-B CME credits. CME expires 04/01/2026.

Specialty CME Credits: Included as part of the 4 credits, this CME activity is eligible for 4 Trauma CME credits, subject to your state and institutional approval.

Authors

Peer Reviewers

Abstract

Education regarding ballistic injuries in the emergency department is sparse and may rarely be encountered if not training or practicing in a trauma center or a military wartime setting. This article provides a comprehensive review on the management of ballistic injuries in the emergency department, including how to assess and manage gunshot wounds, how to recognize when further imaging or evaluation is needed, and how to recognize when transfer to another facility is required. Algorithms are proposed for the management of gunshot wounds based on body part: head, neck, chest and abdomen, and extremities/soft tissue.

Case Presentations

A Level I trauma alert gunshot wound to the head is paged out by EMS and they are at the back door of the ambulance bay with a 32-year-old man…

• Per EMS report, the man was shot in a drive-by shooting. The patient is being ventilated by bag-valve mask. He has a Glasgow Coma Scale score of 7. He has an obvious gunshot wound to his left temple and the crown of his head, with brain matter exposed.
• He is tachycardic and hypertensive, with bilateral breath sounds and good distal pulses.
• You intubate him and consider: What is the best next step to help prevent further neurologic injury?

A 44-year-old woman presents by EMS after sustaining a gunshot wound to the left flank…

• Per EMS report, the patient was shot while fleeing a robbery.
• She arrives awake, alert, and oriented to person, place, and time, but she is notably hypotensive.
• Her E-FAST is negative, and you consider: What is the best next step to effectively resuscitate her?

The transfer center calls and reports that EMS is 15 minutes out with a 76-year-old man who suffered a gunshot wound to the left knee…

• According to the patient, he was cleaning his pistol when he accidentally discharged the firearm into his left lower extremity.
• On initial examination, you note that the distal dorsalis pedis pulse is weak in the left leg, but the patient’s pain is well-controlled.
• CT angiography shows a tibial plateau fracture with intact vasculature. On repeat evaluation 30 minutes after imaging, the patient reports excruciating pain and tingling in his left leg. What are the likely causes of the change in his examination, and what should be the best next step in managing this patient’s injury?

Accreditation:

EB Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.