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

Risk Management Pitfalls For Gunshot Wounds

  1. “The patient presented with a severe penetrating head injury. I’m aware that brain edema is a big problem in these injuries, so I avoided giving IV fluids to him.” Under-resuscitation of head injury leads to hypotension and results in increased morbidity and mortality. Fluid resuscitation should not be withheld for fear of brain edema. If edema is a serious concern, resuscitation with hypertonic saline can be instituted.
  2. “EMS brought in a young male with a gunshot wound to his neck and a GCS score of 6. It was obvious that the patient was not protecting his airway, but I was hesitant to secure the airway due to the possible complications.” Studies have shown that application of RSI to patients with penetrating neck injuries is safe and effective. The emergency clinician should not avoid securing the airway in the trauma patient if it is needed; however, backup airway devices should be available in case of complications.
  3. “A young woman presented to the ED with a small puncture wound on her neck between her clavicle and her cricoid cartilage. The wound looked small, so I decided to suture up the wound and send her home.” Be wary of the penetrating neck injury. Unless you can definitively prove that the wound does not penetrate the platysma, the patient with a penetrating neck injury must undergo a series of imaging studies and/or a period of observation to ensure that no serious injury has occurred.
  4. “The patient had a through-and-through gunshot wound to his arm. The wound on the front of the arm was smaller than on the back of the arm, so I documented in the chart that the entrance wound was located on the front of the arm.” Be careful with your documentation of gunshot wounds. Your chart should contain only descriptions of the wound and factual information about the case. You do not know which wound is the entrance wound, as not all entrance wounds are smaller than exit wounds.
  5. “I didn’t give the patient antibiotics because bullets are sterile, due to the high heat associated with missile injuries.” Numerous studies have proven that bullets are not sterile, and even if they were, the vacuum created by cavitation facilitates inoculating the patient with infectious material such as clothing or other debris.
  6. “Shotguns are low-velocity weapons, so I didn’t think it could be so serious.” Shotguns are devastatingly effective at closer ranges, despite their “low” velocity and less-aerodynamic projectiles. Avoid making judgments solely on velocity classifications and adhere to the maxim “treat the wound, not the weapon.”
  7. “He had a through-and-through wound in his leg, so I didn’t think he could get compartment syndrome.”  Compartment syndrome is a clinical diagnosis, and intracompartment pressures should be measured to verify the diagnosis. Just because the patient has a big hole in his leg doesn’t mean that swelling doesn’t occur or he couldn’t have a hematoma that effectively serves as a tamponade.
  8. “I saw a pulsatile bleeding vessel, and it was easy to see, so I clamped it off for hemostasis.” Clamping of a vessel is ill-advised, as you’re likely to damage a closely approximated nerve and will damage the vessel end, making re-anastomosis more difficult. You could have used a tourniquet or direct pressure instead!
  9. “The entrance wound appears on the anterior chest wall and the exit wound can be found in the lower back . . .” When describing ballistic wounds, do not try to be a forensic pathologist or a detective. Simply describe the wound’s size and appearance, but do not describe it as an entrance or exit wound.
  10. “He is awake and pain is under control, but his blood pressure is only 95/55 mm Hg. Do we need to give him another bolus of crystalloid to get his blood pressure back to normal?” There are 2 pitfalls in this question. First, the primary resuscitative fluid in penetrating trauma should be blood products in an equal ratio rather than crystalloid or colloid. The second pitfall is attempting to maintain a “normal” blood pressure. Multiple studies have demonstrated that permissive hypotension is a useful prehospital and ED strategy that complements the idea of damage control resuscitation. If a patient is awake and alert and tolerating permissive hypotension, it is best to try to maintain the mean arterial pressure around 65 mm Hg or the SBP around 90 mm Hg to decrease bleeding. For more information about damage control resuscitation, see the November 2011 issue of Emergency Medicine Practice, “Traumatic Hemorrhagic Shock: Advances In Fluid Management.”
 
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Last Modified: 07/19/2018
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