Case Presentation & Conclusion
Case Presentation & Conclusion
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.
The 25-year-old male with the gunshot wound to the upper abdomen and the left-lower-lobe injury was taken to the operating room immediately. On visual inspection during thoracotomy, he was found to have a diaphragmatic injury. He required a left-lower-lobe resection but did not have any other intra-abdominal injuries, and he recovered slowly over several weeks.
The 18-year-old male with the shotgun wound to the left leg had multiple small fragments in that leg and APIs of 0.8. Given the extent of his injuries, he was taken to the operating room by an orthopedic surgeon for an external fixator and to wash out and clean up his wounds. He had a preoperative CTA of his left leg that did not reveal a vascular injury. He was eventually discharged for further outpatient orthopedics care.
The 38-year-old man with a gunshot wound to the head was found at the CT scanner to have massive intraparenchymal hemorrhage and significantly increased ICP, collapsing the ventricles and causing herniation. The bullet was in his left temporal lobe. Despite attempts to control his ICP, his injuries were not survivable. Comfort care was provided, and he died in the ICU.
David Bruner; Corey G. Gustafson; Catherine Visintainer
December 2, 2011