Thread: GSW to chest
View Single Post
Old 01-27-2009, 20:35   #7
Doc Dutch
Trauma Surgeon
 
Join Date: Sep 2007
Posts: 83
Sorry, I am late, team. I was out of town looking at several trauma systems in San Diego to learn trauma PI and QI.

Okay . . . The patient on arrival was talking and looked good. He states he saw the gun pulled out and go up and turned to run but heard only one shot (probably unreliable) but stated he had no shortness of breath. He had no past medical history and his review of systems was negative except for this GSW. He noted he felt pain instantly in his back and then his arm as he was running and someone called 911. The assailant fled.

In the trauma bay he had a blood pressure of 110/80 and a heart rate of 80 his RR was between 12 and 20 on the nurses notes and was easily weaned over to nasal canulla with 100% SaO2 on two liters of oxygen.

I was suspicious for a chest injury on the patch phone, but once I saw him and laid eyes on his wounds, I was thinking "through and through" GSW injury.

Now, our next study was a chest X-ray (which was normal) and there was no blood in the chest, no pulmonary contusion, no rib fractures or foreign body. That coupled with no SOB, we took off the oxygen and he did fine with his SaO2.

After about 15 minutes and another few sets of normal vital signs, I cancelled the labs and the CT of chest which had been ordered by my residents. We did obtain left shoulder and brachial films to rule out fractures which were negative.

On PE, he had a normal examination (except for the GSW's and minimal blood loss) with good breath sounds and heart rate. His left upper extremity had a good range of motion without deformities and equal palable pusles in the radial arteries and equal blood pressures in the bilateral upper extremities. He had equal strengths in each upper extremity except only limited by pain on the left.

We gave the patient IV antibiotics and a tetanus shot as he could not remember when his last tetanus shot was given. Coupled with some morphine IV, we gave Percocet PO. We cleansed his arm of the blood, left the wounds open to drain and bandaged them with Xeroform followed by a Kerlix wrap to the arm and 4 x 4's to his shoulder with tape.

In terms of organs, the civilian GSW's are mostly low caliber and not AK-47's or the like. So, for hand guns like we see in Phoenix, Arizona, blast effect is less of an issue than for instance OIF/OEF. Most of the injuries are direct trauma to the organs that are hit by the bullet, but you must at least think about blast effect to the lungs, ribs, heart, etc. In this case, I had to think about humerus fracture, joint (shoulder) involvement, muscle trauma, and neurovascular injuries. So, checking blood pressures in each extremity and light touch/muscle strength examination are important as well as ROM to rule out fractures and joint involvment.

So, on follow-up in the clinic, he was well, breathing normally with a good blood pressure and pulse, healing wounds, no cellulitis, with good pain control (pain almost gone), using his arm well.

Any thoughts or differing ideas? Would anyone have handled it differently? It seemed straight forward.

Thanks,

D-
Doc Dutch is offline   Reply With Quote