Extremeties

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Extremities are the most common locations for GSWs. Initial evaluation should begin with typical ATLS® recommendations for ABCDEs. Brisk bleeding should be treated with direct pressure and tourniquet, if necessary. If a tourniquet is already in place, the time it was placed should be noted during the EMS report. During evaluation, the tourniquet should be taken down carefully. If there is obvious arterial bleeding, a pulse deficit, or pulsatile hematoma, immediate transfer to the operating room is indicated.

In the hemodynamically stable patient without obvious arterial bleeding, initial evaluation of extremity GSWs should begin with physical examination and x-ray imaging. Fractures and foreign bodies are usually easily identified. (See Figure 7.) If there is concern for vascular injury without any hard signs in the lower extremities (eg, pallor, paralysis, paresthesias, pulse deficit, bruit/thrill, expanding hematoma, pulsatile bleeding), an ankle brachial index (ABI) may be obtained. This is performed by placing a manual blood pressure cuff just above the ankle and an ultrasound or Doppler transducer at the dorsalis pedis pulse. Inflate the cuff until the sound of the pulse disappears and then deflate until the sound returns; record this pressure. Do the same at the upper arm, but place the ultrasound or Doppler transducer at the antecubital fossa over the brachial artery. The ABI is the ankle pressure divided by the arm pressure. Traditionally, an ABI <0.9 mm Hg is concerning for occlusion or injury.