What is the appropriate management of a through-and-through gunshot wound to the left thigh?

Management of Through-and-Through Gunshot Wound to the Left Thigh

Immediately assess for active hemorrhage and hard signs of vascular injury—if present with hemodynamic instability, apply a tourniquet proximally, initiate massive transfusion protocol, and transfer directly to the operating room for surgical bleeding control. 1, 2

Immediate Hemorrhage Control

• If active bleeding is present and direct compression fails, apply a tourniquet proximally on the thigh 1
• Re-evaluate tourniquet effectiveness and location as soon as possible to minimize ischemia time and tissue damage 1
• If bleeding stops with direct pressure alone, avoid tourniquet placement 1
• Critical pitfall: Iterative tourniquet releases to "spare ischemia" actually worsen local muscle injury and systemic rhabdomyolysis—once applied, keep it on until definitive surgical control 1

Hemodynamic Assessment and Resuscitation

• Classify hemorrhage severity immediately: 2, 3

  • Class III (1,500-2,000 mL loss): systolic BP decreased, HR >120, anxious/confused—requires crystalloid AND blood transfusion
  • Class IV (>2,000 mL loss): systolic BP decreased, HR >140, lethargic—requires immediate blood products and emergency surgery

• Use permissive hypotension (systolic BP 80-100 mmHg) until bleeding is surgically controlled—attempting to normalize BP before hemorrhage control increases bleeding 2, 4

• Avoid excessive crystalloid administration, which worsens coagulopathy and causes abdominal compartment syndrome 3, 4

• Initiate massive transfusion protocol immediately for Class III/IV hemorrhage 2, 4

Vascular Injury Assessment

Hard signs of arterial injury mandate immediate surgical exploration or CT angiography if patient is stabilized: 1

• Absent distal pulses
• Pallor
• Neurological sensory or motor deficits
• Pulsatile bleeding
• Audible bruit or palpable thrill

Soft signs warrant CT angiography before deciding on operative vs. non-operative management: 1

• Non-pulsatile hematoma near arterial path

• Neurological deficit suggesting nerve compression

• Proximity of wound trajectory to major vascular axis

• Weak distal pulses

• Calculate Ankle-Brachial Index (ABI) if vascular injury suspected—abnormal values indicate need for CT angiography 1

• Even hemodynamically stable patients can harbor life-threatening vascular injuries—normal vital signs do not exclude serious arterial damage 3

Imaging and Diagnostic Work-Up

• Hemodynamically stable patients without hard signs of vascular injury should undergo CT angiography to identify occult arterial injuries before discharge 1
• Shock Index (SI = heart rate/systolic BP) ≥0.8-1.0 predicts need for massive transfusion and operative intervention 1
• Do not delay operative intervention for extensive imaging if patient is hemodynamically unstable—go directly to OR 4

Antibiotic Prophylaxis

• Administer 48-72 hours of first-generation cephalosporin with or without aminoglycoside for high-velocity gunshot wounds 2, 3, 4
• Add penicillin if gross contamination is present to cover anaerobes (Clostridium species) 2, 3, 4
• Infection rates in civilian gunshot wounds are relatively low (2-4%), but high-energy injuries and retained fragments significantly increase risk 3

Surgical Indications

Immediate operative intervention required for: 5

• Unstable fractures requiring operative stabilization
• Intra-articular injuries
• Significant soft-tissue injury with skin loss
• Vascular injury with hard signs
• Large or expanding hematoma

Non-operative management appropriate for: 5

• Minimal soft-tissue disruption
• No nerve, intra-articular, or vascular injury
• Stable, non-articular fractures
• Hemodynamically stable patients with retained fragments in soft tissue 3

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 2, 3
• Monitor hemoglobin serially and consider surgery if more than 2-4 units of transfusion required in 24 hours 2, 3
• Do not rely on negative CT alone to discharge patients—clinical assessment over 48 hours with serial examinations is mandatory 3
• Do not discharge based on initial hemodynamic stability alone, as delayed complications can occur 3

Critical Pitfalls to Avoid

• Do not use rigid cervical collar or spinal board in penetrating trauma—spinal immobilization in gunshot wounds is associated with increased mortality without benefit 3, 4
• Do not hyperventilate during resuscitation—hyperventilated trauma patients have increased mortality 3, 4
• Do not attempt wide excision of all tissue along the wound path—treat the wound based on actual tissue damage, not the weapon type 6
• Do not remove retained bullets unless they cause specific complications—stable patients with retained fragments can be managed non-operatively 3, 7

Transport Considerations

• All gunshot wounds to extremities proximal to the knee require immediate transport to a Level I trauma center regardless of initial hemodynamic stability 2
• Transport to facility with 24/7 access to trauma surgeons, vascular surgeons, orthopedic surgeons, equipped operating theaters, and ICU 2