What is the most appropriate course of action for a patient with a gunshot wound to the thigh, stable vital signs, and no immediate complications?

Management of Isolated Gunshot Wound to the Thigh with Stable Hemodynamics

For this hemodynamically stable patient with an isolated extremity gunshot wound, normal ankle-brachial index (0.98), soft compartments, and no active bleeding or expanding hematoma, observation with serial physical examinations is the most appropriate course of action. 1

Rationale for Non-Operative Management

The key principle is that hemodynamic stability and absence of hard signs of vascular injury allow for selective non-operative management in penetrating extremity trauma. 1 This patient demonstrates:

• Normal hemodynamics (BP 140/95, HR 92) indicating no significant ongoing hemorrhage 1
• Normal ankle-brachial index of 0.98 (normal is >0.9), effectively ruling out clinically significant arterial injury 2
• Soft compartments excluding compartment syndrome 3
• No expanding hematoma or active bleeding from the wounds 1
• Equal pulses in all extremities indicating intact distal perfusion 2, 3

Why Advanced Imaging is Not Indicated

CT angiography is not warranted in this clinical scenario because the patient lacks hard signs of vascular injury. 1 The normal ankle-brachial index has high sensitivity and specificity for excluding arterial injury requiring intervention. 2 CT angiography would be indicated if there were:

• Hemodynamic instability 1
• Absent or diminished pulses 2
• Expanding or pulsatile hematoma 1
• Active arterial bleeding 1
• Abnormal ankle-brachial index (<0.9) 2

Venography has no role in the acute management of extremity gunshot wounds, as venous injuries in stable patients are managed conservatively. 3

Why Surgical Exploration is Not Required

Operative exploration is reserved for hemodynamically unstable patients or those with hard signs of vascular injury, peritonitis, or compartment syndrome. 1 The traditional approach of mandatory exploration for all penetrating wounds has been replaced by selective management based on clinical findings. 1, 3

Low-velocity gunshot wounds to extremities without vascular compromise can be safely managed non-operatively with local wound care. 3 Up to 25% of exploratory procedures in stable patients with penetrating trauma are non-therapeutic, supporting a selective approach. 1

Components of Appropriate Observation

Serial clinical examinations are the gold standard for detecting evolving complications in penetrating extremity trauma. 1 The observation protocol should include:

• Serial physical examinations every 4-6 hours for at least 24-48 hours to detect changes in neurovascular status, compartment tension, or expanding hematoma 1
• Serial hemoglobin measurements to identify occult ongoing bleeding 1
• Continuous monitoring of vital signs for early detection of hemodynamic deterioration 4
• Repeated assessment of compartments for development of compartment syndrome 3
• Evaluation of distal pulses and perfusion at regular intervals 2, 3

Wound Management

Local wound care is appropriate for low-velocity extremity gunshot wounds without deep tissue involvement. 3 This includes:

• Thorough irrigation of the entrance and exit wounds 5
• Debridement of obviously devitalized tissue at the wound margins 3, 5
• Perioperative antibiotic prophylaxis (first-generation cephalosporin) for 24-48 hours, though evidence for routine antibiotics in clean low-velocity extremity wounds is limited 6, 3

Extensive debridement, fasciotomy, and aggressive surgical exploration are only indicated for high-velocity wounds with significant soft tissue destruction or compartment syndrome. 3, 5

Critical Pitfalls to Avoid

• Do not pursue CT angiography in stable patients with normal physical examination and normal ABI, as this leads to unnecessary radiation exposure, cost, and potential false-positive findings requiring further intervention 1
• Do not perform routine operative exploration in the absence of hard signs of injury, as this increases morbidity without improving outcomes 1
• Do not discharge the patient without adequate observation period, as delayed complications can occur 1
• Do not miss evolving compartment syndrome by failing to perform serial compartment assessments 3

When to Escalate Care

Immediate surgical consultation and intervention are indicated if the patient develops: 1

• Hemodynamic instability or signs of ongoing hemorrhage 1
• Development of hard signs of vascular injury (absent pulses, expanding hematoma, pulsatile bleeding) 1, 2
• Compartment syndrome (tense compartments, pain out of proportion, progressive neurologic deficit) 3
• Hemoglobin drop >2 g/dL without alternative explanation 1