Gunshot Wounds (Arms and Legs)

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* 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* No-Signers* No additional management for vascular injury required 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 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)