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

Table of Contents

 

About This Issue

Although there are some general principles for the emergency management of patients with gunshot wounds, such as prehospital care/transport and managing hemorrhage, further treatment strategies will depend on where the most life-threatening wound is located: the head, neck, abdomen/chest/pelvis, or extremity. In this issue, you will learn:

The latest evidence on managing hemorrhage, including tourniquet use, IV fluid resuscitation, permissive hypotension, and blood transfusion.

When x-ray is useful to obtain, and the types of injuries E-FAST can and cannot identify.

Management of gunshot wounds to the head, including airway management, oxygenation, seizure prophylaxis, and prevention of elevated intracranial pressure.

Identification of the zones of the neck to determine likelihood of airway compromise.

The use of imaging and examination findings to identify likely injuries to the chest, abdomen, and pelvis: pneumothorax, hemothorax, cardiac tamponade, and massive hemorrhage.

The criteria for determining the patient’s need for resuscitation with massive transfusion protocol.

Management of extremity injuries, including fractures, soft-tissue injury, and compartment syndrome.

Special considerations in managing gunshot wounds in pregnant and pediatric patients.

1. About This Issue
2. Abstract
3. Case Presentations
4. Introduction
5. Critical Appraisal of the Literature
6. Epidemiology
   1. Firearm Projectile Terminology
   2. Basics of Ballistic Wounds
7. Prehospital Care
   1. Immediate Transport Versus On-Scene Stabilization
   2. Managing Hemorrhage
   3. Tourniquet Use
   4. Intravenous Fluid Resuscitation
   5. Spinal Immobilization
   6. EMS Reporting
8. Emergency Department Evaluation
   1. History and Physical Examination
      1. Re-Evaluation
9. Diagnostic Studies
   1. Laboratory Studies
   2. Imaging Studies
      1. X-Ray
      2. Ultrasound
      3. Computed Tomography
10. Treatment
    1. Gunshot Wounds to the Head
       1. Initial Evaluation
       2. Airway Management
       3. Oxygenation
       4. Circulation
       5. Imaging
       6. Non-Cerebral Injury
       7. Medications
       8. Adjunct Treatments
       9. Prognosis
       10. Summary: Gunshot Wounds to the Head
    2. Gunshot Wounds to the Neck
       1. Zones of the Neck
       2. Hard and Soft Signs of Worsening Injury and Airway Compromise
       3. Intubation for Patients With Mouth and Neck Trauma
       4. Imaging
    3. Gunshot Wounds to the Chest and Abdomen
       1. Pneumothorax
       2. Hemothorax
       3. Pericardial Effusion and Cardiac Tamponade
       4. Massive Hemorrhage and Indications for Massive Transfusion Protocol
       5. Emergency Department Thoracotomy
       6. Abdominal, Pelvic, and Genitourinary Injury
    4. Gunshot Wounds to the Extremities and Soft Tissue
       1. Initial Evaluation
       2. Imaging
       3. Fractures
       4. Soft-Tissue Injuries
       5. Compartment Syndrome
11. Special Populations
    1. Pregnant Patients
    2. Pediatric Patients
12. Controversies and Cutting Edge
    1. Long-Term Outcomes and Futility of Care
    2. Legal Considerations
13. Disposition
    1. Other Considerations
       1. Lead Poisoning
14. Summary
15. Time- and Cost-Effective Strategies
16. 5 Things That Will Change Your Practice
17. Risk Management Pitfalls in Managing Gunshot Wounds in the Emergency Department
18. Case Conclusions
19. Clinical Pathways
    1. Clinical Pathway for Emergency Department Management of Gunshot Wounds to the Head
    2. Clinical Pathway for Emergency Department Management of Gunshot Wounds to the Neck
    3. Clinical Pathway for Emergency Department Management of Gunshot Wounds to the Chest or Abdomen
    4. Clinical Pathway for Emergency Department Management of Gunshot Wounds to the Extremities
20. Tables and Figures
21. References

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?

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Clinical Pathways

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Tables and Figures

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Key References

Following are the most informative references cited in this paper, as determined by the authors.

5. * Shin EH, Sabino JM, Nanos GP 3rd, et al. Ballistic trauma: lessons learned from Iraq and Afghanistan. Semin Plast Surg. 2015;29(1):10-19. (Review) DOI: 10.1055/s-0035-1544173

22. * Velopulos CG, Shihab HM, Lottenberg L, et al. Prehospital spine immobilization/spinal motion restriction in penetrating trauma: a practice management guideline from the Eastern Association for the Surgery of Trauma (EAST). J Trauma Acute Care Surg. 2018;84(5):736-744. (Practice guidelines) DOI: 10.1097/TA.0000000000001764

28. * Alvis-Miranda HR, Rubiano A M, Agrawal A, et al. Craniocerebral gunshot injuries; a review of the current literature. Bull Emerg Trauma. 2016;4(2):65-74. (Review)

93. * Raza S, Thiruchelvam D, Redelmeier DA. Death and long-term disability after gun injury: a cohort analysis. CMAJ Open. 2020;8(3):E469-E478. (Cohort analysis; 8313 patients) DOI: 10.9778/cmajo.20190200

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Keywords: gunshot, ballistics, cavitation, tourniquet, hemorrhage, rhabdomyolysis, E-FAST, intubation, seizure, hemothorax, pneumothorax, tamponade, transfusion, fracture, compartment