What is the plan of care for a patient with a right lower extremity gunshot wound?

Plan of Care for Right Lower Extremity Gunshot Wound

Patients with right lower extremity gunshot wounds require immediate assessment for hemorrhagic shock and vascular injury, with those presenting in shock or with hard signs of vascular compromise requiring immediate surgical bleeding control, while hemodynamically stable patients can undergo systematic evaluation and selective operative management. 1

Immediate Assessment and Resuscitation

Hemodynamic Status Classification

• Class I hemorrhage (<750 ml blood loss): Heart rate <100 bpm, normal blood pressure, minimal intervention needed 1
• Class II hemorrhage (750-1,500 ml): Heart rate 100-120 bpm, normal blood pressure but decreased pulse pressure, requires crystalloid resuscitation 1
• Class III hemorrhage (1,500-2,000 ml): Heart rate >120 bpm, decreased systolic blood pressure, anxious/confused mental status—requires crystalloid and blood transfusion 1, 2
• Class IV hemorrhage (>2,000 ml): Heart rate >140 bpm, decreased blood pressure, lethargic—requires immediate operative intervention 1, 2

Shock Index Assessment

• Calculate Shock Index (heart rate divided by systolic blood pressure) 1
• SI ≥0.9-1.0 predicts need for massive transfusion, interventional radiology, or operative intervention 1
• SI ≥0.8 has 85% sensitivity for predicting massive transfusion 1

Immediate Surgical Indications

All patients arriving in hemorrhagic shock following gunshot wounds are candidates for rapid transfer to the operating room for immediate bleeding control unless initial resuscitation measures are successful. 1, 3, 2

Hard Signs Requiring Immediate Surgery

• Active pulsatile bleeding or expanding hematoma 3, 2
• Absent distal pulses or signs of limb ischemia 3, 2, 4
• Fractures around the knee (highest risk for vascular injury—5 of 12 knee fractures had associated vascular injury requiring repair) 4
• Hemodynamic instability despite resuscitation (systolic BP <90 mmHg, heart rate >120 bpm) 1, 2

Systematic Evaluation for Stable Patients

Physical Examination Priorities

• Document entrance and exit wounds precisely 5
• Assess neurovascular status: popliteal vessels are most commonly injured (60% of vascular injuries in lower extremity gunshot wounds) 4
• Evaluate for nerve injuries: deep peroneal nerve most commonly affected (38% of nerve injuries) 4
• Examine for fractures: 75% occur in lower extremity, 81% involve long bones 4

Imaging Protocol

• Plain radiographs of the entire extremity to identify fractures and bullet trajectory 2, 5
• CT angiography if vascular injury suspected but no hard signs present 2
• Do not rely on negative imaging alone—serial clinical examination over 48 hours is the gold standard 2

Operative Management

Wound Exploration Indications

• High-velocity wounds with significant soft tissue disruption, bullet fragmentation, or comminuted fractures require formal surgical exploration and debridement 3, 6, 7
• Low-velocity wounds with minimal soft tissue injury and no functional deficits can be managed with local wound care 1, 7
• Fractures around the knee mandate vascular exploration given 42% risk of associated vascular injury 4

Fracture Fixation Strategy

• External fixation is preferred initially (33% of cases) for comminuted fractures, unstable patients, or significant soft tissue injury 4, 8
• Intramedullary nailing used in 25% of cases for stable fracture patterns with adequate soft tissue coverage 4
• 20% of fractures can be managed with debridement alone without hardware fixation 4
• Never perform primary wound closure—wounds must heal by secondary intention or require delayed reconstruction 6

Vascular Repair

• Immediate repair required for all identified arterial injuries 3, 2, 4
• Popliteal vessel injuries require urgent intervention to prevent limb loss 4

Antibiotic Management

Initiate antibiotics as soon as possible and continue for 48-72 hours for high-velocity gunshot wounds. 1, 3, 2

Antibiotic Selection

• First-generation cephalosporin (e.g., cefazolin) with or without aminoglycoside for most wounds 1, 3, 2
• Add penicillin for gross contamination or soil exposure to cover anaerobes, particularly Clostridium species 1, 3, 2
• Low-velocity wounds: Antibiotic use is controversial (infection rate 3-4% with or without antibiotics) 1

Critical Pitfalls to Avoid

• Do not hyperventilate during resuscitation—increases mortality in hemorrhagic shock 1, 3, 2
• Avoid excessive crystalloid administration—worsens coagulopathy and causes abdominal compartment syndrome 2
• Do not discharge based on negative imaging alone—requires 48 hours of serial clinical monitoring 3, 2
• Do not assume low-velocity wounds are benign—surface appearance does not predict internal injury 5, 7
• Maintain permissive hypotension (systolic BP 80-100 mmHg) until bleeding is controlled 2

Monitoring and Follow-up

• Serial hemoglobin monitoring every 4-6 hours for first 48 hours 2
• Repeat neurovascular examinations every 4-6 hours 2
• Consider surgery if >2-4 units transfusion required in 24 hours 2
• Average time to full weight-bearing is 66 weeks (range 4-267 weeks) for complex injuries 8
• Overall complication rate is 20% 4