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Evaluate 5 important structures when evaluating gunshot wounds in an extremity.
Blood Vessel Injuries
- 3 Categories
- Hard-Signers
- Mnemonic: HARD Bruit
- Hypotension
- Arterial/pulsatile bleeding
- Rapidly expanding hematoma
- Deficits (pulse)
- Audible BRUIT/thrill
- These patients likely need OR
- Mnemonic: HARD Bruit
- Soft-Signers
- Significant vascular oozing/bleeding
- Large hematoma
- These patients need to be screened with ABI (ankle brachial index)
- ABI <0.9 or asymmetry between extremities is concerning for vascular injury
- If abnormal, obtain a CTA
- These patients need to be screened with ABI (ankle brachial index)
- No-Signers
- No additional management for vascular injury required
- Hard-Signers
Nerve Injuries
- Relatively rare
- Document neuro exam in the extremity
- Consult if abnormal
Bone Injuries
- Relatively common
- Diagnosed by x-ray
- Consult orthopedics for fracture
Soft Tissue Injury
- Be sure to count/document number of holes
- Typically do not need laceration repair unless cosmetic area
- Don’t miss compartment syndrome
- Mnemonic: “P’s”
- Pain out of Proportion
- Pain with Passive range of motion
- Paresthesias
- Pallor
- Paralysis
- Poikilothermia
- Mnemonic: “P’s”
The Bullet: What To Do With It?
- The bullet is almost never removed, unless…
- Very superficial/cosmetic and easy to remove
- In a joint
Additional Reading
- NBME Shelf Review Part 2- Trauma (EM Clerkship)
The neck trauma podcast listed neurologic deficit as a hard sign. Would you send a patient to the OR for neuro deficit with GSW to the neck? what about GSW to the extremity?
If a patient has hard signs after neck trauma, they will almost certainly need the OR. For extremity trauma, it depends on the deficit and what could potentially be repaired.