What are the key things to watch out for in a patient with a gunshot wound?

Key Things to Watch Out for in Gunshot Wounds

Hemodynamically stable patients with gunshot wounds can harbor life-threatening injuries despite normal vital signs, mandating aggressive diagnostic work-up and serial clinical monitoring, as stable appearance does not reliably exclude serious vascular, cardiac, or visceral injuries. 1, 2

Immediate Life-Threatening Concerns

Hemorrhagic Shock Classification and Recognition

• Class III hemorrhage (1,500-2,000 ml blood loss): decreased systolic BP, heart rate >120 bpm, anxious/confused mental status—requires crystalloid and blood transfusion 1, 3
• Class IV hemorrhage (>2,000 ml blood loss): decreased systolic BP, heart rate >140 bpm, lethargic mental status—requires immediate crystalloid, blood products, and emergency surgical intervention 1, 3
• All patients arriving in shock following gunshot wounds require rapid transfer to the operating room 1

The "Stable" Patient Pitfall

• 16% of hemodynamically stable patients with transmediastinal gunshot wounds have life-threatening cardiac, vascular, or tracheoesophageal injuries requiring urgent operation 2
• Vital signs, blood gas values, and initial chest tube output do not reliably differentiate patients with serious injuries from those without 2
• Hemodynamic stability is defined as systolic BP ≥90 mmHg and heart rate 50-110 bpm, but this does not exclude major injury 3

Anatomic Region-Specific Concerns

Abdominal Injuries

• Hard signs of bowel injury on CT (free fluid, mesenteric stranding, bowel wall thickening, contrast extravasation, or metallic fragments within intestinal wall/lumen) mandate surgical exploration 1
• CT has only 88% sensitivity for detecting bowel injury in gunshot wounds—negative imaging does not exclude injury 1
• Penetrating abdominal gunshot wounds with signs of severe hypovolemic shock require early surgical bleeding control 1

Ureteral Injuries (Often Missed)

• Direct ureteral inspection is necessary during laparotomy in patients suspected to have ureteral injury who proceed without adequate preoperative imaging 4
• Use adjunctive maneuvers: careful ipsilateral ureteral mobilization and/or IV methylene blue or indigo carmine to identify injuries 4
• Ureteral contusion from blast injury can lead to delayed stricture or overt necrosis with urinary extravasation—intact but contused ureters should be stented or resected with primary repair, particularly after gunshot wounds 4
• Intraoperative single-shot IVP cannot reliably exclude ureteral injury and should not be used solely for this purpose 4

Mediastinal Injuries

• Transmediastinal gunshot wounds require aggressive work-up with chest radiograph, cardiac ultrasound, angiography, esophagoscopy, barium swallow, and bronchoscopy based on missile trajectory 2
• Cardiac, vascular, pulmonary, and digestive structures are at risk even in stable patients 2

Extremity Injuries

• High-velocity gunshot wounds cause radial tissue damage from kinetic energy transfer and require more aggressive surgical management than low-velocity wounds 1, 3
• Unstable fractures require operative stabilization 1, 3
• Arterial injuries requiring vascular surgery must be identified early 3

Wound Assessment Challenges

Entrance vs. Exit Wound Misidentification

• 37% of single exiting gunshot wounds and 73.6% of multiple gunshot wounds are misinterpreted by trauma specialists regarding entrance/exit identification and total number of wounds 5
• Surgical alteration and healing between injury and evaluation complicate accurate assessment 5
• Each gunshot wound must be treated individually due to variability in tumbling, fragmentation, unimpeded passage, and cavitation potential 1

Management Principles

Antibiotic Prophylaxis

• 48-72 hours of first-generation cephalosporin with or without aminoglycoside for high-velocity gunshot wounds 1, 3, 6
• Add penicillin for gross contamination to cover anaerobes (Clostridium species) 1, 3, 6
• Infection rates in civilian settings are relatively low (approximately 2-4%), but high-energy injuries and retained fragments significantly increase this risk 1, 3

Surgical Timing Decisions

• Stable patients with ureteral lacerations should undergo repair at time of laparotomy, though immediate repair may not be appropriate in unstable, complex polytrauma patients 4
• In damage control settings, urinary extravasation can be prevented with ureteral ligation followed by percutaneous nephrostomy or externalized ureteral catheter, with definitive repair when stabilized 4
• Hemodynamically stable patients with retained metallic fragments in soft tissue can be managed non-operatively with close monitoring 1

Resuscitation Pitfalls

• Avoid hyperventilation during resuscitation of severely hypovolemic trauma patients, as it increases mortality 1
• Avoid excessive crystalloid administration that can worsen coagulopathy and cause abdominal compartment syndrome 6
• Use permissive hypotension (systolic BP 80-100 mmHg) until major bleeding is controlled 6

Spinal Immobilization

• Do not routinely use rigid cervical collar or spinal board in penetrating trauma—spinal immobilization in gunshot wounds is associated with increased mortality without benefit in neurological deficits 6
• Manual in-line stabilization is only indicated during intubation procedures in suspected cervical lesions 6

Monitoring Requirements

Serial Clinical Evaluation

• Serial clinical evaluation every 4-6 hours for at least 48 hours is the gold standard for deciding operative versus non-operative management 6
• Do not rely on negative CT alone to discharge patients—clinical assessment over 48 hours with serial examinations is required 1
• Monitor hemoglobin serially and consider surgery if more than 2-4 units of transfusion are required in 24 hours 6