“We are 7 minutes out with a 26-year-old male with a gunshot wound in the right leg. No other visible bullet wounds at this time. He is alert and oriented, complaining of severe right leg pain. He did hear multiple shots. Vital signs are currently stable and his bleeding is well controlled with a tourniquet. Any questions?” This a common EMS patch that we hear in the emergency department in downtown Boston. This has also become very topical in the press with Chicago’s recent dismal statistics. Given these, I thought it would be a good time to cover gunshot wounds to the extremity.
Trauma to the extremities (arms and legs) is actually one of the most common injuries that we see in the emergency department. While not all of them involve gunshot wounds, many of them are assessed in same manner. We want to make sure that there has been no injury to the blood vessels, bones, nerves and tissue (ligaments/tendons). Many of these injuries require input from multiple specialists. They may require a general/trauma surgeon, an orthopedic specialist, a surgeon that specializes in blood vessels, or plastic surgeons.
One of the first things pre-hospital is to control bleeding. The paramedics in our case did a great job of that by applying a tourniquet. Depending on the location on of the gunshot wound, there may be lots of blood or very little blood. A tourniquet can often stop aggressive bleeding if applied correctly. An important part of the evaluation is knowing the anatomy of the limb that is affected. If you know where the underlying structures are, you can help predict what part of the body is going to be injured.
When the patient is brought in with a gunshot wound to an extremity, the first thing that we do is a trauma survey. This includes a primary survey, followed by a secondary survey. We do this the same way for every single trauma patient so nothing is missed. The primary survey checks airway, breathing and circulation. If this is intact we will go on to a secondary survey. In a gunshot wound, this involves stripping the patient completely naked and inspecting EVERY inch of their body from armpits to groin. If the patient is unstable with trauma, they may go directly to an operating room to stabilize life-threatening injuries. If we determine that it is an isolated injury to an extremity, and it’s stable, we will then perform a detailed exam of the extremity assessing for any damage to the structures we listed above. This includes (blood vessels, bones, nerves and tissue). We will then order testing based on these findings. All gunshot wounds of the extremity will have an x-ray to assess for metal fragments and broken bones. It also allows us to have a rough idea of the course of the bullet as we can see where the bullet is in relation to the entry wound. Bullets can enter the leg and end up in the belly or chest cavity. If there are concerns about damage to the blood vessels on the patient’s exam we will then go on to check the blood vessels with special tests called angiography. The injuries that are present will determine the work up that takes place.
If the patient is stable with an isolated injury but has an injury to the blood vessels in the leg, it depends how severe the injury is. If they have significant findings they will go to the operating room with a surgeon who specializes in fixing blood vessels (vascular surgeon). If there are broken bones at the same time, a surgery coordinated between the vascular surgeon and the orthopedic surgeon will take place.
If the patient is stable with an isolated injury but has no injury to blood vessels we will try to identify other injuries. If broken bones are present, the extent of these broken bones will be assessed and possibly go to the operating room to fix
It's important to note that patients who have these injuries can have a high rate of complications including infections in the bones, developing blood clots, breakdown of soft tissue, tendon/ligament injury and infection.
In our case the patient was admitted to the hospital, received antibiotics and tetanus shot. His gunshot wound was cleaned out with sterile water and loosely stitched. There was no injury to the vessels or tendons, and was discharged after a day in the hospital. Until next month!