Initial Management of Gunshot Wounds
Immediately assess hemodynamic stability (systolic BP ≥90 mmHg, HR 50-110 bpm) and classify hemorrhage severity using ATLS criteria to determine if the patient requires immediate surgical intervention or can proceed with imaging and selective operative management. 1
Primary Assessment and Hemodynamic Stabilization
Hemodynamic status determines the entire management pathway:
Hemodynamically unstable patients (Class III: BP decreased, HR >120, blood loss 1,500-2,000 mL; or Class IV: BP decreased, HR >140, blood loss >2,000 mL) require immediate crystalloid resuscitation, blood products, and emergency surgical bleeding control 1
Hemodynamically stable patients can undergo imaging evaluation before proceeding to selective operative intervention based on specific injury patterns 1, 2
Patients who stabilize after simple immediate resuscitation should receive careful physical examination looking specifically for signs of vascular damage, which determines imaging strategy 2
Imaging Strategy
CT with IV contrast is the procedure of choice for stable patients:
Total body CT identifies hemorrhage, air, bullet fragments, bone fragments, hemothorax, nerve lesions, musculoskeletal injuries, and vascular injuries 2
Routine plain radiographs should be obtained initially in all gunshot wound patients 2
CT is indicated based on presence of signs/symptoms of vascular damage at clinical examination 2
Common pitfall: Intraoperative single-shot IVP cannot reliably exclude ureteral injury in abdominal/pelvic wounds and should not be used solely for this purpose 3
Wound Classification and Surgical Decision-Making
Energy transfer efficiency matters more than velocity alone:
High-velocity wounds (>609.6 m/s or >2,000 feet/second) typically cause radial tissue damage from kinetic energy transfer and require more aggressive surgical management 1, 4
Low-velocity wounds (<609.6 m/s or <2,000 feet/second) can often be treated nonoperatively with local wound care 4
However, velocity classification can be misleading—energy transfer efficiency depends on projectile deformation, fragmentation, stability, entrance profile, path through body, and tissue characteristics 2, 4
High-velocity wounds with limited soft tissue disruption, no significant functional deficits, no bullet fragmentation, and minimal bony involvement may be candidates for simple wound care 4
Operative Management Principles
Surgical exploration is indicated for:
Hemodynamically unstable patients requiring immediate bleeding control 1
High-energy injuries with significant soft tissue disruption 4
Grossly contaminated wounds requiring irrigation and debridement 4
Unstable fractures requiring operative stabilization 1
When exploring wounds:
Perform decompression and excision of necrotic tissue, assessing muscle viability by color, consistency, contractility, and capacity to bleed 4
For suspected ureteral injuries during laparotomy without preoperative imaging, directly inspect ureters using careful mobilization and/or IV/intraureteral dyes (methylene blue or indigo carmine) 3
In stable patients, repair traumatic ureteral lacerations at time of laparotomy 3
In unstable polytrauma patients, use damage control approach with temporary urinary drainage (ureteral ligation with percutaneous nephrostomy or externalized ureteral catheter), followed by delayed definitive repair 3
Antibiotic Prophylaxis
The American Academy of Orthopaedic Surgeons recommends:
48-72 hours of antibiotic therapy for high-velocity gunshot wounds using first-generation cephalosporin with or without aminoglycoside 1
Add penicillin for gross contamination to cover anaerobes (Clostridium species) 1
Note: Infection rates in civilian settings are relatively low (approximately 2-4%), with wound infection occurring in approximately 1.9% of cases 1