II. Pathophysiology

  1. Stab Wounds (or other hand initiated projectiles)
    1. Lacerate local tissues along the weapon path
  2. Medium velocity Gunshot Wound (e.g. handguns)
    1. Can create a cavity 5-6 times the bullet diameter
    2. Yaw (rotation of the bullet on its long axis) results in greater cavitation and secondary injury
  3. High-velocity Gunshot Wound (especially >600 m/sec, hunting or military rifles, or magnum rounds with increased gunpowder)
    1. Transmits energy more broadly to more distant tissue via shock waves
    2. Results in cavity up to 30x the diameter of the bullet (depending on bullet velocity, contact area, underlying tissue)
    3. Bullets may ricochet off bony structures and fragment into multiple projectiles with individual destructive paths
    4. Injuries from semijacketed or hollow-point bullets increase the degree of injury due to flattening on impact and increasing contact surface area
  4. Shotgun wound (360 m/sec at muzzle, but individual pellet velocity rapidly declines)
    1. Shotguns can cause fatal injury at close range
    2. Typically causes low energy impacts of "shot" at distance with each projectile embedding superficially in skin
    3. May result in Retained Foreign Body if "shot" carries with it material from shell casing or clothing

III. Approach: General

  1. Start with stabilization
    1. See ABC Management (Cardiopulmonary Resuscitation)
    2. See Primary Trauma Evaluation
    3. See Secondary Trauma Evaluation
    4. See FAST Exam
    5. Avoid aggressive crystalloid (risk of coagulopathy)
      1. Replace blood losses with Blood Products (order early)
      2. Blood Pressure need not be Restored to fully normal levels (mild permissive Hypotension is preferred)
    6. Hemorrhage control
      1. External pressure to sites of bleeding
      2. Consider Tranexamic Acid (start within first hour)
  2. Evaluate for extent of injury
    1. Path and velocity of penetrating object (match bullet entry wounds to bullets)
    2. Sterile cotton swab or gloved finger may be used to gently probe wound for depth (Exercise caution)
  3. Retained penetrating objects (e.g. knives, impaled objects)
    1. Emergent surgical evaluation
    2. Leave all penetrating objects in place until surgically evaluated
      1. Risk of vascular injury or uncontrollable bleeding with removal under uncontrolled circumstances

IV. Approach: Penetrating Head Injury (intracranial)

  1. See Penetrating Neck Trauma
  2. Imaging
    1. CT Head
    2. CT Angiogram indications
      1. Bullet trajectory approaches vessels near skull base or dural venous sinus
      2. Wound involving face or orbit
      3. Wound involves temporal region (middle meningeal artery region)
      4. Subarachnoid Hemorrhage
      5. Delayed Subdural Hematoma formation
  3. Monitoring
    1. Intracranial Pressure
  4. Management
    1. Prophylactic broad spectrum antibiotics
    2. Seizure Prophylaxis (continued for at least the first week after injury)
    3. Defer penetrating object removal to neurosurgery (risk of vascular injury or increased bleeding)
    4. Open penetrating wounds require careful debridement, and watertight dura closure (CSF-tight)
      1. Scalp Wounds may be temporarily closed to control Hemorrhage
      2. Definitive closure is by surgery

V. Approach: Chest Penetrating Trauma

  1. Evaluation
    1. FAST Exam is highest yield (Pericardial Effusion, Pneumothorax, Hemothorax, intraabdominal bleeding)
    2. Chest imaging (Chest XRay or CT Chest) for negative FAST Exam in a stable patient
      1. Repeat in Chest XRay in 1 hour if initially non-diagnostic (previously 3-6 hours was recommended)
      2. Berg (2013) World J Surg 37(6):1286-90 +PMID:23536101 [PubMed]
      3. Seamon (2008) J Trauma 65(3): 549-53 +PMID:18784567 [PubMed]
  2. Management
    1. Decompress Hemothorax or Pneumothorax (Ultrasound is sufficient to make diagnosis)
    2. Emergent sternotomy in operating room for Pericardial Effusion
    3. Immediate Emergency Thoracotomy for Pericardial Effusion and loss of pulses

VI. Approach: Abdomen and pelvis Penetrating Trauma

  1. Stab Wounds most commonly injure liver, Small Bowel, diaphragm and colon
  2. Evaluation
    1. FAST Exam
      1. Positive intraabdominal blood in Penetrating Trauma is sufficient surgery indication
    2. CT Abdomen and Pelvis with IV contrast
      1. Best for ruling-in surgical abdominal conditions of solid organs in the upper quadrants
      2. Test Sensitivity is not high enough for 100% ruling-out of penetrating GI tract injury
        1. Penetrating abdominal injuries evident on CT are typically also symptomatic
        2. Contrast with gun shot wounds which are well evaluated with CT imaging
    3. Diagnostic Peritoneal Lavage
      1. Used historically, but most U.S. Trauma Centers do not perform now
    4. Local wound exploration
      1. Typically requires local anesthetic and may require Sedation
      2. Evaluate for penetration of anterior fascia and observe if breached
  3. Pregnancy
    1. Gravid, muscular Uterus absorbs considerable energy from Penetrating Trauma
    2. Pregnant women tend to sustain less intrabdominal bowel injury than nonpregnant patients
    3. Fetal injury and death from penetrating Abdominal Trauma is common
  4. Management
    1. Emergent laparotomy for peritonitis, unreliable examination or evisceration
    2. Observe for 12-24 hours and surgery for Tachycardia, increasing Leukocytosis or increasing pain

VII. Approach: Extremity Penetrating Trauma

  1. Exam
    1. Remove all clothing and thoroughly examine injured extremity
    2. Complete extremity neurovascular exam
  2. Diagnostics
    1. Extremity XRay
    2. Arterial Pressure Index (API)

VIII. References

  1. (2008) ATLS, American College Surgeons, Chicago, p. 113-4, 148-9, 287-8
  2. Hicks and Orman in Herbert (2016) EM:Rap 16(4): 9-11
  3. Spangler and Inaba in Herbert (2016) EM:Rap 16(7):14-5

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