What are the guidelines for managing a patient with a gunshot wound?

Management of Gunshot Wounds

All gunshot wounds to the head, neck, torso, and extremities proximal to the elbow and knee require immediate transport to a Level I trauma center regardless of initial hemodynamic stability, as surface examination cannot reliably exclude life-threatening vascular, cardiac, or visceral injuries. 1, 2

Immediate Triage and Transport

Transport directly to a trauma center with the following capabilities: 1

• Immediate access to trauma surgeons, cardiothoracic surgeons, neurosurgeons, vascular surgeons, and orthopedic surgeons
• Equipped operating theaters available 24/7
• Properly equipped ICUs
• Emergency thoracotomy capability

Critical anatomic locations mandating trauma center transport: 1

• All penetrating injuries to head, neck, torso
• Extremity injuries proximal to elbow and knee
• Any associated flail chest, pelvic fractures, or paralysis

Hemodynamic Assessment and Classification

Assess hemorrhage class immediately upon arrival: 2, 3, 4

• 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 AND blood transfusion 2, 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 blood products and emergency surgical intervention 2, 3

All patients arriving in shock following gunshot wounds require rapid transfer to the operating room for surgical bleeding control. 1, 3, 4

Critical Pitfall: Stable Vital Signs Do Not Exclude Major Injury

Hemodynamically stable patients (systolic BP ≥90 mmHg, heart rate 50-110 bpm) can harbor life-threatening injuries despite normal vital signs. 2 This mandates:

• Aggressive diagnostic work-up with CT imaging
• Serial clinical examinations every 4-6 hours for minimum 48 hours 2, 4
• Do NOT discharge based on negative CT alone—clinical assessment over 48 hours is required 2, 4

Resuscitation Principles

Avoid these common lethal errors during resuscitation: 2, 3, 4

• Do NOT hyperventilate severely hypovolemic trauma patients—this increases mortality through cerebral tissue lactic acidosis 1, 3
• Do NOT administer excessive crystalloid—this worsens coagulopathy and causes abdominal compartment syndrome 2, 3
• Use permissive hypotension (systolic BP 80-100 mmHg) until major bleeding is surgically controlled 2, 3
• Initiate massive transfusion protocol immediately for Class III/IV hemorrhage 3

Ventilation strategy: 1

• Use low tidal volume with moderate PEEP
• Avoid high tidal volume (>12 mL/kg) which promotes pulmonary inflammation

Anatomic Region-Specific Management

Torso Gunshot Wounds

Penetrating torso injuries are the highest priority because they may require emergency thoracotomy, a procedure not available at all hospitals. 1 Survival rates for emergency thoracotomy are only 7.3% for gunshot wounds, emphasizing the critical nature of immediate surgical intervention. 1, 3

Abdominal gunshot wounds with severe hypovolemic shock require early surgical bleeding control. 1, 4 Hard signs of bowel injury on CT mandate surgical exploration: 2, 4

• Free fluid
• Mesenteric stranding
• Bowel wall thickening
• Contrast extravasation
• Metallic fragments within intestinal wall/lumen

Critical limitation: CT has only 88% sensitivity for detecting bowel injury in gunshot wounds—negative imaging does not exclude injury. 2, 4

Chest Gunshot Wounds with Shock

The American College of Surgeons recommends immediate transfer to the operating room for surgical bleeding control in patients with penetrating chest injuries and confirmed hypovolemic shock, unless initial resuscitation rapidly restores hemodynamic stability. 3 The 60-minute emergency department time limit for patients in hemorrhagic shock significantly decreases mortality. 3

Extremity Gunshot Wounds

High-velocity gunshot wounds cause radial tissue damage from kinetic energy transfer and require more aggressive surgical management than low-velocity wounds. 2, 3, 5 However, velocity classification alone is misleading—energy transfer efficiency depends on projectile deformation, fragmentation, stability, and tissue characteristics. 5

Operative indications for extremity injuries: 2, 4

• Unstable fractures requiring operative stabilization
• Hard signs of vascular injury requiring vascular surgery
• High-energy injuries with significant soft tissue disruption

Hemodynamically stable patients with retained metallic fragments in soft tissue can be managed non-operatively with close monitoring. 2, 4

Head and Neck Gunshot Wounds

Penetrating injuries to head and neck place vital cardiopulmonary, vascular, and neurologic systems at risk. 1 Vascular damage may result in life-threatening exsanguinating hemorrhage, and nerve damage may result in permanent disability. 1

Zone III facial injuries (above the eyebrows) are independently associated with mortality. 6 These injuries require multispecialty involvement and triage to a trauma center. 6

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, 4

Surgical Wound Management

For low-velocity gunshot wounds: 5

• Majority can be treated safely non-operatively with local wound care
• Outpatient treatment is appropriate for selected cases
• Associated fractures treated similarly to closed fractures

For high-velocity and shotgun wounds: 5

• Soft tissues assume crucial role
• Mandatory irrigation and appropriate debridement
• Use open fracture protocols
• Decompression and excision of necrotic tissue guided by color, consistency, contractility, and capacity to bleed

Monitoring and Serial Assessment

Serial clinical evaluation every 4-6 hours for at least 48 hours is the gold standard for deciding operative versus non-operative management. 2, 4 Monitor hemoglobin serially and consider surgery if more than 2-4 units of transfusion are required in 24 hours. 2

Spinal Immobilization

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 neurological deficits. 2, 3