Gunshot Wounds (Arms and Legs)
EM Clerkship
Zack Olson, MD ; Mike Estephan, MD ; Maddie Watts, MD
4.9 • 816 Ratings
🗓️ 30 July 2017
⏱️ 9 minutes
🧾️ Download transcript
Summary
Evaluate 5 important structures when evaluating gunshot wounds in an extremity.
Blood Vessel Injuries
* 3 Categories* Hard-Signers* Mnemonic: HARD Bruit* Hypotension* Arterial/pulsatile bleeding* Rapidly expanding hematoma* Deficits (pulse)* Audible BRUIT/thrill* These patients likely need OR* Soft-Signers* Significant vascular oozing/bleeding* Large hematoma* These patients need to be screened with ABI (ankle brachial index)* ABI <0.9 or asymmetry between extremities is concerning for vascular injury* If abnormal, obtain a CTA* No-Signers* No additional management for vascular injury required
Nerve Injuries
* Relatively rare* Document neuro exam in the extremity* Consult if abnormal
Bone Injuries
* Relatively common* Diagnosed by x-ray* Consult orthopedics for fracture
Soft Tissue Injury
* Be sure to count/document number of holes* Typically do not need laceration repair unless cosmetic area* Don’t miss compartment syndrome* Mnemonic: “P’s”* Pain out of Proportion* Pain with Passive range of motion* Paresthesias* Pallor* Paralysis* Poikilothermia
The Bullet: What To Do With It?
* The bullet is almost never removed, unless…* Very superficial/cosmetic and easy to remove* In a joint
Additional Reading
* NBME Shelf Review Part 2- Trauma (EM Clerkship)
Transcript
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| 0:00.0 | Hello, med students. |
| 0:03.2 | My name is Zach Olson, and thank you for downloading this week's episode of the EM Clerkship Podcast. |
| 0:12.2 | Close your eyes, unless you're driving. |
| 0:15.5 | Here's your case. |
| 0:20.3 | Okay, this is a unknown name, uncooperative. Okay, this is |
| 0:21.9 | unknown name, uncooperative, |
| 0:24.6 | 23-year-old male, |
| 0:26.1 | alert and oriented times three the whole time, |
| 0:27.9 | no complaints, except for GSW to the left upper arm, |
| 0:32.3 | heard three shots. |
| 0:35.0 | Looks like we have an entrance and exit wound, |
| 0:40.0 | anterior or posterior. But like I said, we couldn't get anything. We did get a pressure of 140 over 70. And that's it. We didn't get |
| 0:44.5 | any history or anything. So any questions? All right. What do you do? |
| 1:05.0 | Last year, we did a ton of trauma and really overviewed things system by system, but we still didn't talk too much about gunshots. The good old gunshot wound, GSW, the truth is, unlike bullets into the belly or chest or neck, which are going to the |
| 1:12.6 | OR, management of bullets into the extremities, into the arms and legs are really common and way |
| 1:20.7 | within the scope of practice of emergency medicine. Today we are talking about bullet wounds, |
| 1:27.4 | specifically into the extremities. |
| 1:30.4 | And what you need to remember, the way to approach this is to think through five structures. |
| 1:35.9 | You got to check the blood vessels, the nerves, the bones, the soft tissues, and the bullet, |
| 1:43.2 | kind of the five structures to check. |
| 1:46.1 | Keep a mental checklist of those five things. |
| 1:48.6 | You'll be covered. |
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