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GSW to chest
Old 01-25-2009, 11:46   #1
Doc Dutch
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GSW to chest

Okay team, it is 2:30 am and you are on-call and you are called by the patch phone that a 19 year old male is coming in with two GSW's and one is to the posterior left chest. They report they are 5 minutes away and coming in hot . . . Vitals BP 108/55, HR 105 to 110, RR 20 (isn't everybody's on the flowsheets?) and the SaO2 are 100% on 100% no-rebreather. He is alert and his GCS is 15 moving all extremities. The patient arrives and here is an attachment. Excluded his face so no one can recognize him but did not take away any of the pertinent physical findings.

Okay, thoughts?

1) What does this represent to you in terms of the GSW?
2) What studies would you get? (Labs, Films,etc)
3) What would you look for on physical exam?
4) How would you treat this injury initially?
5) What organs are you worried about or none at all which gets back to what studies and how you are going to treat this?

I will give you more as answers come in. Good teaching case to run through the drill of patient care and ATLS . . .

D-
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Old 01-25-2009, 11:49   #2
Doc Dutch
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GSW to Chest and upper extremity.jpg
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Old 01-25-2009, 12:31   #3
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Initial thoughts from pic and stats:
BP is low due to loss.
Minimal involvement of pulmonary and cardiac systems - SO2 still good, HR still good.
Based on photos - bleeding is well under initial control - internal loss hard to determine.
Looks as though a single large bore is set on non affected side - clear fluids - therefore a second needs set, for packed cells if available, and SO2 reduces.
concerns based on the 2 visible entry wounds - Humeral and shoulder involvement - possibly brachial nerve, artery and vein involvement.
Proximity to pulmonary cavity gives rise to throbocytic secondary involvement.
Initial films - full upper thoracic and L extremity series (ortho involvement, location of projectiles)
Start GSW ABX therapy as proescribed by local guidelines (not sure if this is civ or Mil)
Labs - CBC, Tox, SO2, Sed
Currnt concerns are pulmonary involvement with traumatic/projectile tamponade - same for major vessel involvement. Ortho involvement in both shoulder and upper L extremity.

without seeing and touching it's a tough call.
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Old 01-25-2009, 12:54   #4
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For the first time, I'll try to give one a go. I'll probably leave out enough stuff so that this will go on for a while, though.

1) I see an entrance wound on the left shoulder and an exit wound on the left upper arm. I do not see an exit wound from the posterior chest GSW, so I am thinking the bullet is still somewhere in the chest. I would be extra cautious when moving the patient.

2) Not so sure about this one. I would grab a CBC, looking at the Hgb/Hct, maybe the WBC depending how long ago he was shot. Grab a chest Xray, looking for the bullet, or a pneumo/hemothorax. Not sure about necessity of a CT scan. Would it be helpful in looking for early signs of cardiac tamponade? CT of the arm help in determining amount of damage? I'll hook him up to a 12-lead, closely monitor his ECG. I would keep monitoring his BP, HR, and RR looking for changes that might be indicative of pneumothorax, tamponade, or compartment syndrome/hypovolemic shock.

3) I would first look at the chest. Listen for breath and heart sounds. This is where I might find cardiac tamponade or pneuomothorax. Percuss on the chest, looking for fluid build-up. Look for even rise and fall of the chest. Monitor for trouble breathing, cyanosis of the fingertips and lips, JVD, tracheal deviation. Also keep monitoring for signs of shock like a fall in BP, cool, clammy skin, confusion, lethargy, and tachycardia. Depending on where the wound is, also check for muscle control of the chest, abdomen and extremities, looking for spinal cord damage. Keep an eye out for damage, maybe peek below the sheets looking for priapism, urinary or fecal incontinence.

For the arm, I would take a radial pulse and check reflexes below the wound, looking for damage to a major artery or nerve. Not sure what else there.

4) All I know is what I've been taught in CLS class, so I'm not sure what to do in a hospital setting. I'd start some oral empiric antibiotics. Broader spectrum, maybe Augmentin? Not too worried about enterics or anaerobes unless we find the bullet somewhere in the gut. Take a wound culture prior to initiation of therapy, adjust as necessary. make sure and get an allergy history as well as immunization history to determine necessity of tetanus immunization.

Chest injury may need a trip to the OR, and placement of a chest tube, but I don't know anything about that.

5) I'm worried about the lungs, the heart, and the spinal cord. Also, about the break in the skin and chance of infection.

I'm sure I left out a lot of stuff, and included a lot of unnecessary stuff, but I would love to learn more.

SR

EDIT: But now that I look at the picture again, I'm not so sure that my answer to #1 is correct. Maybe I am not looking at the picture correctly. Haven't seen any GSW before so I don't really know what entry/exit wounds look like.

Last edited by shr7; 01-25-2009 at 12:59.
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Old 01-25-2009, 17:35   #5
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In additon to what already mentioned:

3) Check for internal bleeding: Inspect for development of bruising on abdomen and back, ask for acute pain in abdominal/torso, palpate for tenderness and rigidity, and keep monitoring vitals and CBC

5) Lung, spleen, and left kidney. CT scan and X-ray of the torso. IV, prophylactic antibiotics. Xray of left arm to check for broken bones and bullet fragments.
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Old 01-25-2009, 18:27   #6
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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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Old 01-27-2009, 20:35   #7
Doc Dutch
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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-
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Old 01-27-2009, 22:50   #8
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If you don't mind. A couple questions about the antibiotics/infection control.

Is there a standard antibiotic for a GSW as opposed to any trauma where the skin is broken? I am assuming that the antibiotic choice is majorly dictated by where the wound is. For example a gut wound would need different coverage than a foot wound, which might need different coverage than a superficial injury to the arm.

In this case, what antibiotics did you start, and why the choice to use IV? Did he receive a first dose IV in the trauma bay, followed by finishing a course PO at home? Or was he admitted to the hospital with multiple days of IV therapy? Or did he just receive 1 dose as a prophylaxis before he was sent home?

I am wondering your thoughts on the subject, because someday when I grow up, I would love to work in an ER.

I am not trying to ask questions that I have not researched, but I haven't been able to find any guidelines on the subject as of yet.

I think my question boils down to, are we using antibiotics as prophylaxis, or as empiric therapy, and what is guiding your decision making in abx selection and IV vs. PO?

Thank you very much

SR
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Old 01-28-2009, 00:17   #9
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shr7-
think about method onf introduction of any microbes - high velocity - traling through systems and with possible small vessel involvement. Thereis amuch larger chance of systemic infection due to method of injury. therfore IV ABX therapy. Choice of ABX is generally based on local protocol and availability, and pt sensitivity. Generally a broad spectrum abx will be used (where did the bullet come from? where has it been, etc...). Hope that helps.

docDutch- I surprised myself, even my semi-dated knowledge covered a majority of the concerns and algorythms you followed. Thanks for the test.
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Sun-Tzu, "The Art of Warfare"

Hearing, I forget. Seeing, I remember. Writing (doing), I understand. Chinese Proverb

Too many people are looking for a magic bullet. As always, shot placement is the key. ~TR
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Old 01-28-2009, 00:39   #10
RichL025
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Quote:
Originally Posted by Doc Dutch View Post

Any thoughts or differing ideas? Would anyone have handled it differently?

D-
Yeah, if I was your resident, I wouldn't have called you until we were heading towards the OR

("I swear Ma'am, he was hypotensive!")

Just kidding.
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Old 01-28-2009, 21:22   #11
Doc Dutch
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Good report, all.

As for antibiotics, it is for prophylaxis strictly. As there is really no infection except to prevent an infection from the skin breakage or dragging clothes through a wound or any other inanimate object with the bullet, antibiotics are just prophylaytic and single dose coverage is adequate. We generally give it IV and during the resuscitation. It is a general broad spectrum antibiotic that has wide covergae and usually we use Ancef 1 gram intravenously. If they have not had a tetanus shot within the last 5 years then they get a new one.

So, shr7 for extremity or soft tissue penetrating trauma, we use Ancef unless they are Pen allergic and then we use Clindamycin and I have also seen Vancomycin used (but heavy handed). This is not for bowel/GI coverage and my next bowel case I will put up on the boards for all to look at and critique and we can discuss antibiotic choice (it is always an appropriate discussion regarding antibiotic stewardship). All antibiotics are given IV because if you give a PO antibiotic and then the patient gets morphine or feels sick due to pain, they could vomit it all up and out, so PO antibiotics are not a good choice!

As for antibiotics versus no antibiotics there is a lot of data in the trauma and surgical literature to give the for open penetrating injuries. Antibiotics are not to be overused in duration and type and they must be discontinued immediately when not needed or when cultures identify that antibiotics can be de-escalated or tailored to the sensitivities of the organism.

RIchLO25 - I must say that "once unstable, always unstable", but in this case we never had a huge blood loss and with the repeat stability of BP and HR, hard to take a patient to the OR and make good better. Now if we go to wash out the wounds and debride them, then I could not argue as the wounds can get washed out better and debrided better. But, they probably don't need such aggressive care as that and can be handled in the ED.

Thanks,

Dutch
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Old 01-29-2009, 11:00   #12
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Quote:
Originally Posted by Doc Dutch View Post
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.
D-
Doc Dutch, I understand the causative organism (staph and strep) and mechanism of cellulitis. Questions:

- Do you expect cellulitis to manifest in a short period of time (minutes, less than 12 hours, I assume the patient is not staying in for days)?
- Can the absence of cellulitis be mosly attributed to the prophylactic intervention?

Thank you for the rationale on IV antibiotics vs. PO. That makes perfect sense.

FF
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Der, der einen Freund verliert, verliert viel mehr;
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Pill Packs
Old 01-30-2009, 10:41   #13
rcm_18d
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Pill Packs

If this was a combat wound, the operators these days are caring a pill pack given by the first responder if conscious. Included in the pill pack is Tylenol 1000mg (mild to moderate pain), Mobic 15 mg (Anti-inflammatory), and Gatafloxin 400mg or equivalent (broad spectrum antibiotic). The TC3 protocol is this is to be given after Primary and Secondary surveys are complete. I am just looking for your thoughts on this. I will agree that if I am the first responder as the Medic the meds will be given I.V. if possible (METT-T). The 82nd did a study with 100 or so combat wounded soldiers and the results were 0 post op infection from the soldiers that were given P.O. antibiotics in the field prior to evac.
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Old 01-30-2009, 11:39   #14
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Hey, rcm:

I think you missed a step.

You might want to go back and read the board rules and stickies, and put up your introduction in the proper place before posting further.

TR
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Old 01-30-2009, 12:11   #15
RichL025
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Quote:
Originally Posted by frostfire View Post
Doc Dutch, I understand the causative organism (staph and strep) and mechanism of cellulitis. Questions:

- Do you expect cellulitis to manifest in a short period of time (minutes, less than 12 hours, I assume the patient is not staying in for days)?
- Can the absence of cellulitis be mosly attributed to the prophylactic intervention?
Since DD is probably busy doing this for real, I'll presume by answering for her.

Cellulitis will not manifest in minutes - typical time frame is measured in days. The scary exception is a certain type of infection that can manifest within 12-24hours called Necrotizing Fasciitis (aka Necrotizing Soft Tissue Infection) - this is basically cellulitis on steroids and can kill rather rapidly. Luckily, 99% of the time, an otherwise healthy combat wound victim won't have to worry about this, but keep it in your mind if you see a cellulitis not responding to traditional Abx in an older diabetic patient (for example) who is getting SICK.

As far as the "abscence" of cellulitis attributed to anything, it's always hard to say. When we decide on providing many of these treatments, we don't do it because there's a slam-dunk cause and effect - we do them because studies show a benefit... in larger populations.

For example, if you line up 100 young otherwise healthy trauma victims with a GSW to the leg (for example), maybe 10 of them will get an infection. Take another group of 100 with identical wounds and give ALL of them prophy Abx. Then maybe 3 of them will get infections. Then we calculate up to cost of giving those 100 guys antibiotics, and compare it to the savings for the 7 guys who DIDN'T get infections because we prophylaxed them. If the costs of the antibiotics are lower, then we give them to our patients.

Note that when I say "costs", I don't mean just money. We also compare the risk of side effects from the antibiotics, and for the cost of the infection we try and figure in things like time lost from work, longer time in the hospital, and risks from the infection progressing to something more serious (like the Nec Fasc I mentioned above).

If all that sounds like very fuzzy science, IT IS! Now factor in the fact that we performed those studies in young healthy patients, then we try to apply the same findings to make treatment decisions in an 80 year old diabetic MVC victim... do the same rationales apply?

A LARGE amount of what we do in medicine is based on decision-making like above... generalizing the results of large studies to individual patients and trying to make rational treatment decisions.

So, in a very long winded way, I probably didn't answer your question as to whether the prophy abx saved the patient from cellulitis... but hopefully I showed you a little of the reason why it's not a straightfoward question...

RL
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