What is the initial assessment and treatment for a previously healthy adult with a gunshot wound?

Initial Assessment and Treatment of Gunshot Wounds in Previously Healthy Adults

All patients with gunshot wounds require immediate assessment for hemorrhagic shock and rapid transfer to the operating room if presenting with hemodynamic instability, as stable vital signs do not reliably exclude life-threatening injuries. 1, 2

Immediate Life-Threatening Assessment

Hemorrhage Classification and Response

Classify shock severity immediately upon arrival to guide resuscitation intensity 1, 3:

• Class III hemorrhage (1,500-2,000 mL blood loss): Decreased systolic BP, heart rate >120 bpm, respiratory rate 30-40/min, anxious/confused mental status—requires crystalloid resuscitation AND blood transfusion 4, 1, 3

• Class IV hemorrhage (>2,000 mL blood loss): Decreased systolic BP, heart rate >140 bpm, respiratory rate >40/min, lethargic mental status—requires immediate crystalloid, blood products via massive transfusion protocol, and emergency surgical intervention 4, 1, 3

• All patients arriving in shock following gunshot wounds are candidates for rapid transfer to the operating room regardless of anatomic location 4, 2, 3

Critical Resuscitation Principles

Apply permissive hypotension (systolic BP 80-100 mmHg) until surgical bleeding control is achieved, as attempting to normalize blood pressure before hemorrhage control increases bleeding 3

Avoid hyperventilation during resuscitation—hyperventilated trauma patients have increased mortality compared to non-hyperventilated patients 4, 3

Limit crystalloid administration to prevent worsening coagulopathy and abdominal compartment syndrome 1, 3

Use protective ventilation with low tidal volume and moderate PEEP to prevent acute lung injury in patients requiring mechanical ventilation 4

Anatomic Region-Specific Evaluation

Penetrating Abdominal Gunshot Wounds

Penetrating abdominal gunshot wounds with signs of severe hypovolemic shock require immediate surgical bleeding control without delay for imaging 4, 1, 2

For hemodynamically stable patients, obtain CT with IV contrast 5:

• Hard signs of bowel injury on CT mandate surgical exploration: free fluid, mesenteric stranding, bowel wall thickening, contrast extravasation, or metallic fragments within intestinal wall/lumen 1, 2

• CT has only 88% sensitivity for detecting bowel injury—negative imaging does not exclude injury and requires serial clinical monitoring 1, 2

Chest Injuries

The 60-minute emergency department time limit for patients in hemorrhagic shock from penetrating chest trauma significantly decreases mortality 3

Obtain chest x-ray in all stable patients to identify hemothorax, pneumothorax, and bullet trajectory 5

CT with IV contrast identifies hemorrhage, hemothorax, vascular injuries, and anatomical structures at risk 5

Genitourinary Injuries

Gunshot wounds cause ureteral injuries in approximately 1/3 of penetrating trauma cases, with blast effects extending 2 cm from the bullet path 4

Direct ureteral inspection is necessary during laparotomy in patients suspected to have ureteral injury who proceed without adequate preoperative imaging 1

Ureteral contusion from blast injury can lead to delayed stricture or overt necrosis—intact but contused ureters should be stented or resected with primary repair 1

Bladder injury is present in 3.6% of abdominal gunshot injuries and 20% of penetrating buttock injuries 4

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, 2

Unstable fractures require operative stabilization 1, 2

Obtain x-rays to identify fractures, retained fragments, and vascular injuries 5

Head Injuries

All cranial gunshot patients should initially receive aggressive resuscitation with intubation 6

If Glasgow Coma Scale (GCS) score after resuscitation is 3-5 and no operable hematomas are present on CT, no further surgical therapy should be offered due to universally poor outcomes 6

All patients with GCS >5 should receive aggressive surgical therapy with rapid debridement 6

Surgical Management Principles

Wound Debridement

Standard treatment consists of primary and prompt detailed debridement, sufficient fasciotomy, and complete drainage of the wound 7, 8

Each gunshot wound must be treated individually due to variability in tumbling, fragmentation, and cavitation potential 2

Non-Operative Management

Hemodynamically stable patients with retained metallic fragments in soft tissue can be managed non-operatively with close monitoring 1, 2

Antibiotic Prophylaxis

Administer 48-72 hours of first-generation cephalosporin with or without aminoglycoside for high-velocity gunshot wounds 1, 2, 3

Add penicillin for gross contamination to cover anaerobes (Clostridium species) 1, 2, 3

Infection rates in civilian settings are relatively low (approximately 2-4%), but high-energy injuries and retained fragments significantly increase this risk 1, 2

Monitoring Requirements

Serial clinical evaluation every 4-6 hours for at least 48 hours is the gold standard for deciding operative versus non-operative management 1

Do not rely on negative CT alone to discharge patients—clinical assessment over 48 hours with serial examinations is required 1, 2

Monitor hemoglobin serially and consider surgery if more than 2-4 units of transfusion are required in 24 hours 1

Critical Pitfalls to Avoid

Do not use spinal immobilization—rigid cervical collars and spinal boards in penetrating trauma are associated with increased mortality without benefit in neurological deficits 1, 3

Do not delay operative intervention for extensive imaging in hemodynamically unstable patients—they should go directly to the operating room 3

Hemodynamic stability (systolic BP ≥90 mmHg, heart rate 50-110 bpm) does not exclude major injury—stable patients can harbor life-threatening injuries requiring aggressive diagnostic work-up 1