What's the best approach to treat a young adult with no significant past medical history and a gunshot wound to the chest in a small emergency room (ER) setting?

Management of Gunshot Wound to the Chest in a Small ER

For a hemodynamically stable young adult with a gunshot wound to the chest in a small ER, immediately perform chest radiography followed by CT chest with IV contrast to identify life-threatening injuries, then arrange urgent transfer to a Level I trauma center with immediate surgical capabilities while managing any pneumothorax or hemothorax with tube thoracostomy. 1

Immediate Hemodynamic Assessment

Determine hemodynamic stability first—this dictates your entire management pathway. 1, 2

• Hemodynamically stable = systolic BP ≥90 mmHg and heart rate 50-110 bpm 3
• Class III hemorrhage = 1,500-2,000 ml blood loss, decreased BP, HR >120, anxious/confused mental status 2, 3
• Class IV hemorrhage = >2,000 ml blood loss, decreased BP, HR >140, lethargic mental status 2, 3

If the patient is in hemorrhagic shock (Class III or IV), initiate massive transfusion protocol and arrange immediate transfer to the operating room at a trauma center—imaging should not delay surgical intervention. 2, 4

Initial Imaging Protocol for Stable Patients

Start with chest radiography immediately at bedside to identify pneumothorax, hemothorax, rib fractures, and bullet trajectory. 1

• Chest X-ray can recognize contusions, pneumothorax, hemothorax, rib fractures, foreign bodies/ballistic fragments, and mediastinal injuries that require immediate treatment 1
• However, chest radiography has significant limitations and cannot adequately assess vascular injuries, cardiac injuries, or minimal pneumothorax 1, 5

Proceed immediately to CT chest with IV contrast if the patient remains hemodynamically stable—this is the definitive imaging modality. 1

• CT chest with IV contrast has a 99% negative predictive value for triaging hemodynamically stable patients with penetrating chest trauma 1
• CT successfully excludes the need for surgery in patients with nonsignificant radiologic findings 1
• CT adequately identifies vascular injuries including pseudoaneurysms, intimal flaps, filling defects, and contrast extravasation 1
• CT provides fast, noninvasive assessment of missile trajectories and decreases the need for routine angiographic and esophageal studies 1

Never use CT chest without IV contrast for gunshot wounds—noncontrast imaging is inadequate to definitively evaluate vascular injuries in ballistic trauma. 1

Critical Anatomic Zones Requiring Special Attention

Pay particular attention to the "cardiac box"—defined by the sternal notch superiorly, xiphoid process inferiorly, and nipples laterally. 1

• Patients with injuries in this region can rapidly decompensate 1
• CT imaging can identify findings suggestive of cardiac injury such as hemopericardium and pneumopericardium 1

Consider whole-body CTA because multiple injuries and active bleeding are common in penetrating thoracic trauma, and bullet trajectories are unpredictable. 1

• CTA of the abdomen and pelvis should be used liberally because terminal ballistics of bullets and fragments may have unpredictable trajectories 1

Immediate Interventions in the Small ER

Perform tube thoracostomy immediately for pneumothorax or hemothorax—this remains the most common treatment for penetrating chest injury and can be done in any ER. 6, 7

• Chest tube thoracostomy is sufficient in approximately 92% of penetrating chest injuries 7
• Only 8% of patients require thoracotomy 7

Initiate antibiotic prophylaxis with first-generation cephalosporin with or without aminoglycoside for 48-72 hours. 2, 3

• Add penicillin if there is gross contamination to cover anaerobes (Clostridium species) 2, 3
• Infection rates in civilian settings are relatively low (approximately 2-4%), but high-energy injuries increase this risk 2

Transfer Decision-Making

All patients with penetrating torso injuries require transfer to a Level I trauma center with immediate thoracotomy capabilities, regardless of initial stability. 1, 8

• Penetrating torso injuries have survival rates of only 7.3% for gunshot wounds requiring emergency thoracotomy 1, 8
• Surface examination of the wound frequently does not allow adequate analysis of the extent of underlying injury 1, 8
• Penetrating injuries to the chest place vital cardiopulmonary, vascular, and neurologic systems at risk 1, 8
• Rapid intervention may be needed to prevent morbidity and mortality, requiring access to cardiothoracic surgeons, vascular surgeons, and neurosurgeons 1, 8

Patients can be safely discharged from a trauma center only after short-term repeat chest radiographs if they remain asymptomatic with unremarkable imaging. 1

Common Pitfalls to Avoid

Do not rely on external wound appearance alone—surface wounds frequently do not reveal the extent of underlying injury due to bullet tumbling and fragmentation. 1, 8, 2

Do not delay transfer for extensive imaging if the patient shows any signs of hemodynamic instability—patients arriving in shock following gunshot wounds are candidates for rapid transfer to the operating theater. 2

Do not hyperventilate during resuscitation of severely hypovolemic trauma patients—this increases mortality. 2

Do not assume a single imaging modality is sufficient—each gunshot wound must be treated individually due to variability in tumbling, fragmentation, and cavitation potential. 2

Do not discharge patients based on negative initial chest radiograph alone—CT identifies additional findings that may require intervention, and short-term observation with repeat imaging is necessary. 1