What is the initial assessment and treatment for a patient with a gunshot wound?

Initial Assessment and Emergent Treatment of Gunshot Wounds

Immediate Life-Threatening Assessment

All patients with gunshot wounds presenting in hemorrhagic shock require immediate transfer to the operating room for surgical bleeding control, regardless of the anatomic location of injury. 1, 2, 3

Hemorrhage Classification and Response

Rapidly classify hemorrhage severity using the Advanced Trauma Life Support system to guide resuscitation intensity 1:

• Class I (<750 ml loss): Heart rate <100, normal blood pressure, minimal anxiety—requires crystalloid only 1
• Class II (750-1,500 ml loss): Heart rate >100, normal blood pressure but decreased pulse pressure, mild anxiety—requires crystalloid and type-specific blood 1
• Class III (1,500-2,000 ml loss): Heart rate >120, decreased systolic blood pressure, anxious/confused mental status—requires immediate crystalloid and blood transfusion with type-specific blood 1, 2
• Class IV (>2,000 ml loss): Heart rate >140, decreased systolic blood pressure, lethargic mental status—requires immediate crystalloid, emergency blood release, and immediate surgical intervention 1, 2

Critical Caveat About "Stable" Patients

Hemodynamically stable patients (systolic BP ≥90 mmHg, heart rate 50-110 bpm) can harbor life-threatening injuries despite normal vital signs, mandating aggressive diagnostic work-up and serial clinical monitoring for at least 48 hours. 2, 4 Stable appearance does not reliably exclude serious vascular, cardiac, or visceral injuries 2.

Resuscitation Principles

Permissive Hypotension Strategy

• Target systolic blood pressure 80-100 mmHg until major bleeding is surgically controlled 2
• Avoid excessive crystalloid administration that worsens coagulopathy and causes abdominal compartment syndrome 2
• Use blood products early in Class III and IV hemorrhage rather than crystalloid alone 1, 2

Ventilation Management

• Avoid hyperventilation during resuscitation of severely hypovolemic trauma patients, as it increases mortality 2, 3
• Use low tidal volume ventilation (not 12 ml/kg) with moderate PEEP to prevent acute lung injury, particularly in bleeding trauma patients 1
• Hypocapnia (<27 mmHg) causes cerebral tissue lactic acidosis and neuronal injury via glutamate release 1

Spinal Precautions

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 preventing neurological deficits. 2

Anatomic Region-Specific Management

Abdominal Gunshot Wounds

All penetrating abdominal gunshot wounds with signs of severe hypovolemic shock require immediate laparotomy for early surgical bleeding control. 1, 2, 3 This is true to a lesser extent for stab wounds but is absolute for gunshot wounds 1.

For hemodynamically stable patients 5, 6:

• Obtain CT imaging with intravenous contrast to identify hemorrhage, air, bullet fragments, and organ injuries 6
• Hard signs of bowel injury on CT (free fluid, mesenteric stranding, bowel wall thickening, contrast extravasation, or metallic fragments within intestinal wall/lumen) mandate immediate surgical exploration 2, 3
• CT has only 88% sensitivity for detecting bowel injury—negative imaging does not exclude injury 2, 3
• Surgical revision of the abdominal cavity is indicated for all penetrating abdominal gunshot injuries 5

Extremity Gunshot Wounds

High-velocity gunshot wounds (>609.6 m/s) cause radial tissue damage from kinetic energy transfer and require more aggressive surgical management than low-velocity wounds. 2, 4, 6

Management approach 2, 4, 7:

• Unstable fractures require operative stabilization 2, 3, 4
• Identify arterial injuries requiring vascular surgery early through physical examination and CT angiography 2, 4
• High-energy injuries and grossly contaminated wounds mandate irrigation, appropriate debridement, fasciotomy, and complete drainage using open fracture protocols 8, 5, 7
• Hemodynamically stable patients with retained metallic fragments in soft tissue can be managed non-operatively with close monitoring 2, 3

Thoracic Gunshot Wounds

• Obtain chest CT to identify hemothorax, pneumothorax, cardiac injury, and great vessel injury 6
• Thoracotomy is indicated for massive hemothorax, cardiac tamponade, or great vessel injury 5

Genitourinary Injuries

• Direct ureteral inspection is necessary during laparotomy in patients suspected to have ureteral injury who proceed without adequate preoperative imaging 2
• 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 2

Antibiotic Prophylaxis

Administer 48-72 hours of first-generation cephalosporin with or without aminoglycoside for high-velocity gunshot wounds. 2, 3, 4

• Add penicillin for gross contamination to cover anaerobes (Clostridium species) 2, 3, 4
• Infection rates in civilian settings are relatively low (approximately 2-4%), but high-energy injuries and retained fragments significantly increase this risk 2, 3, 4
• Wound infection occurs in approximately 1.9% of cases 4, 5

Wound Management

Surgical Debridement Indications

Standard treatment of deep penetrating gunshot wounds consists of 8, 5, 7:

• Primary and prompt detailed debridement 8
• Sufficient fasciotomy for high-energy wounds 8, 5
• Complete drainage of the wound 8, 5
• Assessment of muscle viability based on color, consistency, contractility, and capacity to bleed 7

Non-Operative Wound Management

Simple wound irrigation and local wound care is appropriate for low-velocity gunshot wounds with limited soft tissue disruption, no significant functional deficits, no evidence of bullet fragmentation, and minimal bony involvement. 7

Monitoring and Disposition

Serial Clinical Evaluation Protocol

Serial clinical evaluation every 4-6 hours for at least 48 hours is the gold standard for deciding operative versus non-operative management. 2

• Do not rely on negative CT alone to discharge patients—clinical assessment over 48 hours with serial examinations is required 2, 3
• Monitor hemoglobin serially and consider surgery if more than 2-4 units of transfusion are required in 24 hours 2
• After 24 hours without complications in truly stable patients, discharge can be considered 6

Rare Complications Requiring Vigilance

Bullet embolus is a rare but potentially fatal complication causing distal limb ischemia, coronary infarct, renal infarction, stroke, pulmonary embolization, cardiac valvular injury, thrombophlebitis, and dysrhythmias. 9 Thorough physical exam and appropriate imaging are vital to prompt identification, as surgical embolectomy or endovascular retrieval are the preferred treatments 9.