What is the location of the patient's gunshot wound?

Determining Gunshot Wound Location

I cannot determine where this specific patient was shot based on the question alone—you must perform a focused physical examination documenting all entrance and exit wounds, obtain plain radiographs to identify bullet trajectory and retained fragments, and proceed with CT imaging if the patient is hemodynamically stable.

Immediate Assessment Protocol

The location of gunshot wounds must be systematically identified through physical examination and imaging, as surface wounds frequently do not reveal the extent of underlying injury. 1

Physical Examination Requirements

• Document all visible entrance and exit wounds on the head, neck, torso, and extremities, as penetrating injuries to these regions place vital cardiopulmonary, vascular, and neurologic systems at risk. 1

• Examine specifically for wounds to high-risk anatomic zones:

  • Head and neck (risk of vascular exsanguination and neurologic injury) 1
  • Torso including chest and abdomen (may require emergency thoracotomy) 1
  • Proximal extremities above the elbow and knee (vascular and nerve damage risk) 1

• Assess hemodynamic status immediately: systolic BP ≥90 mmHg and heart rate 50-110 bpm defines stability, but this does not exclude major injury. 2, 3

Mandatory Imaging Sequence

• Obtain routine plain radiographs first to identify bullet location, trajectory, bone fragments, and retained metallic fragments. 4

• Proceed to total body CT with IV contrast if the patient is hemodynamically stable (systolic BP ≥90 mmHg, HR 50-110 bpm) to identify hemorrhage, air, bullet fragments, organ damage, and vascular injuries. 2, 4

• CT has only 88% sensitivity for detecting bowel injury in gunshot wounds—negative imaging does not exclude injury and requires serial clinical monitoring for 48-72 hours. 2, 5

Critical Anatomic Considerations

The wound location determines mortality risk and required surgical capabilities:

• Penetrating torso injuries have the highest priority for trauma center triage, with survival rates of only 7.3% for gunshot wounds requiring emergency thoracotomy. 1

• Head, neck, and proximal extremity wounds require immediate access to neurosurgeons, vascular surgeons, and cardiothoracic surgeons at the highest level trauma center. 1

• High-velocity wounds cause radial tissue damage from kinetic energy transfer beyond the visible wound tract, requiring more aggressive surgical management. 2, 3

Common Pitfalls

• Do not rely on external wound appearance alone—surface examination frequently fails to reveal the extent of underlying injury, and bullet trajectory can be unpredictable due to tumbling and fragmentation. 1, 5

• Hemodynamic stability does not exclude life-threatening injury—stable patients can harbor serious vascular, cardiac, or visceral injuries requiring aggressive diagnostic work-up. 2

• Never discharge based on negative CT alone—serial clinical evaluation every 4-6 hours for at least 48 hours is the gold standard for operative versus non-operative management decisions. 2, 5