Thread: GSW to chest
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Old 01-25-2009, 18:27   #6
Odd Job
Guerrilla
 
Join Date: May 2006
Location: London (ex SA)
Posts: 107
I trust you won't think me impudent to offer my two South African cents, but I must make a comment based on how I have seen a few of these go down.

There is potential for misadventure and being lead astray if one concentrates too much on skin breaches in these gunshot cases. If Doc Dutch has specified a posterior breach also, then the total number of breaches is three or more. In most cases (including this one) that means you can't automatically assume that any two breaches are associated with one trajectory. What the ambulance crew tells you may not be accurate (in terms of the number of GSWs).
There are multiple possibilities in this case:

1) The two visible breaches are related to one perforating GSW (does not mean that you can declare the direction of perforation) or assume that the perforation occurred on a straight line.

2) One of the breaches is associated with the posterior breach that has not been photographed (a medium length perforation) and the other is associated with a penetrating injury of unknown length.

3) Both of those visible breaches are associated with perforating GSWs and the fourth breach has not yet been found.

What I am saying is that too much effort can be expended on trying to assume what the damage may be, when allowing oneself to be influenced by skin breach positions in the first instance.

As it stands and with the information provided so far, I would venture that his first CXR should be done supine on account of the fact that you can't exclude thoracic spine involvement. Clinical examination plus gross findings on CXR will tell you how much sand is in the egg timer for you to get the T-spine imaging (would depend on any clues seen on the supine CXR which way to go, if your protocol doesn't say anything). Just make sure to have the skin breaches marked with paperclips prior to X-ray.
Once the T-spine is cleared, I would go for erect CXR and possibly abdo also, depending on whether we had visibility of the projectile or projectile fragments.

This case is similar to one I have in my file, but I won't comment further on that one, because this is about Doc's case, not mine.
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