<< Ballistic Injuries In The Emergency Department (Trauma CME)

Emergency Department Evaluation

History

If the patient’s overall status permits, certain historical information may help the clinician in management. If the patient is unable to provide any historical information, EMS personnel or friends/family present may be able to assist with providing information. Per ATLS® protocol, an “AMPLE” history should be taken at a minimum (see Table 4) along with the following questions.²⁸

• What type of weapon was used? Handguns are low-velocity weapons and typically involve less kinetic energy transfer than high-velocity rifles or the variable force and pattern of shotgun injuries. If the patient or witness can tell you the type of gun used, it may help you anticipate unseen injuries.
• How far away were you from the weapon at the time it was fired and at what angle were you when it hit? This may help to anticipate the missile’s trajectory and possible pathway through the body in order to determine which skin wound is the likely entrance wound and to anticipate potential injury patterns and locations.
• How many shots did you hear? There may only be 2 visible surface injuries, which can lead you to assume entry and exit wounds, but if there were 2 shots fired, possibly neither bullet found an exit track and both are still inside the patient. This will also prompt you to continue to look for more missile wounds that may not initially be visible.

Curiosity will often lead the emergency clinician to ask about the circumstances of the ballistic injury, but these details are rarely helpful except to determine whether the wound was self-inflicted, which will require later psychiatric evaluation after the traumatic injuries are addressed and the patient is stabilized. For more information on assessing depressed and suicidal patients in the ED, see the September 2011 issue of Emergency Medicine Practice, “The Depressed Patient And Suicidal Patient In The Emergency Department: Evidence-Based Management And Treatment Strategies.” Tetanus status should be obtained, and prophylaxis is indicated for most gunshot wounds.

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