Clinical Pathways
Clinical Pathways
No Vascular Injury
No Vascular Injury

No Vascular Injury

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Decision

Is there concern for bony injury on examination and imaging?

Background

Fractures

GSWs with fractures identified on examination and imaging should be washed out, stabilized, and splinted. There is no consensus on whether prophylactic antibiotics should be used for these injuries, but it should be considered, as these patients are at higher risk for infection than soft-tissue GSWs. Data regarding open fractures, in general, recommend prophylactic antibiotics. The 2011 EAST guidelines, based on Level 1 evidence, recommend agents effective against Staphylococcus aureus, such as a first-generation cephalosporin (cefazolin IV), given as soon as possible after the injury. Orthopedics should be consulted on patients with open fractures, but typically, unless the fracture is highly comminuted, unstable, or intra-articular, outpatient management can be pursued.

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References
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  66. Goel R, Zhu X, Makhani S, et al. Blood transfusions in gunshot-wound-related emergency department visits and hospitalizations in the United States. Transfusion. 2021;61(8):2277-2289. (Retrospective review; 168,315 patients)
  67. Vasudeva M, Mathew JK, Groombridge C, et al. Hypocalcemia in trauma patients:a systematic review. J Trauma Acute Care Surg. 2021;90(2):396-402. (Systematic review; 3 studies, 1213 patients)
  68. Cap AP, Pidcoke HF, Spinella P, et al. Damage control resuscitation. Mil Med. 2018;183(suppl_2):36-43. (Review)
  69. Miller M, Kruit N, Heldreich C, et al. Hemodynamic response after rapid sequence induction with ketamine in out-of-hospital patients at risk of shock as defined by the shock index. Ann Emerg Med. 2016;68(2):181-188. (Prospective observational study; 112 patients)
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  73. Sodagari F, Katz DS, Menias CO, et al. Imaging evaluation of abdominopelvic gunshot trauma. Radiographics. 2020;40(6):1766-1788. (Review)
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  75. Martin MJ, Brown CVR, Shatz DV, et al. Evaluation and management of abdominal gunshot wounds: a Western Trauma Association critical decisions algorithm. J Trauma Acute Care Surg. 2019;87(5):1220-1227. (Practice guidelines)
  76. Joseph B, Zeeshan M, Sakran JV, et al. Nationwide analysis of resuscitative endovascular balloon occlusion of the aorta in civilian trauma. JAMA Surg.2019;154(6):500-508. (Case-control study; 593,818 patients)
  77. Heller MT, Oto A, Allen BC, et al. ACR Appropriateness Criteria Penetrating Trauma-Lower Abdomen and Pelvis. J Am Coll Radiol. 2019;16(11s):S392-S398. (Practice guidelines)

    78. ®

  78. Bailey MA, Griffin KJ, Scott DJ. Clinical assessment of patients with peripheral arterial disease. Semin Intervent Radiol. 2014;31(4):292-299. (Review)
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  80. Fox N, Rajani RR, Bokhari F, et al. Evaluation and management of penetrating lower extremity arterial trauma: an Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg. 2012;73(5 Suppl 4):S315-S320.(Practice guidelines)
  81. Omid R, Stone MA, Zalavras CG, et al. Gunshot wounds to the upper extremity. J Am Acad Orthop Surg. 2019;27(7):e301-e310. (Review)
  82. Eardley WG, Stewart MP. Early management of ballistic hand trauma. J Am Acad Orthop Surg. 2010;18(2):118-126. (Review)
  83. Hoff WS, Bonadies JA, Cachecho R, et al. East Practice Management Guidelines Work Group: update to practice management guidelines for prophylactic antibiotic use in open fractures. J Trauma. 2011;70(3):751-754. (Guidelines)
  84. Shadgan B, Menon M, O’Brien PJ, et al. Diagnostic techniques in acute compartment syndrome of the leg. J Orthop Trauma. 2008;22(8):581-587. (Review; 66 studies)
  85. Molina GA, Aguayo WG, Cevallos JM, et al. Prenatal gunshot wound, a rare cause of maternal and fetus trauma, a case report. Int J Surg Case Rep. 2019;59:201-204. (Case report)
  86. Flaherty MR, Klig JE. Firearm-related injuries in children and adolescents: an emergency and critical care perspective. Curr Opin Pediatr. 2020;32(3):349-353.(Review)
  87. Parikh K, Silver A, Patel SJ, et al. Pediatric firearm-related injuries in the United States. Hosp Pediatr. 2017;7(6):303-312. (Review)
  88. Abujamra L, Joseph MM. Penetrating neck injuries in children: a retrospective review. Pediatr Emerg Care. 2003;19(5):308-313. (Retrospective review; 148,000 patients)
  89. Karaca MA, Kartal ND, Erbil B, et al. Evaluation of gunshot wounds in the emergency department. Ulus Travma Acil Cerrahi Derg. 2015;21(4):248-255. (Retrospective descriptive analysis; 142 patients)
  90. Legrand M, Russell R. What’s new in focused assessment with sonography: ballistic trauma. Intensive Care Med. 2016;42(11):1787-1789. (Review)
  91. Nuttall AG, Paton KM, Kemp AM. To what extent are GCS and AVPU equivalent to each other when assessing the level of consciousness of children with head injury? A cross-sectional study of UK hospital admissions. BMJ Open. 2018;8(11):e023216. (Cross-sectional study; 5700 patients)
  92. Hoffmann F, Schmalhofer M, Lehner M, et al. Comparison of the AVPU scale and the pediatric GCS in prehospital setting. Prehosp Emerg Care. 2016;20(4):493-498.(Prospective cohort study; 302 children)
  93. Raza S, Thiruchelvam D, Redelmeier DA. Death and long-term disability after gun injury: a cohort analysis. CMAJ Open. 2020;8(3):E469-E478. (Cohort analysis; 8313 patients) DOI: 10.9778/cmajo.20190200
  94. Vella MA, Warshauer A, Tortorello G, et al. Long-term functional, psychological, emotional, and social outcomes in survivors of firearm injuries. JAMA Surg.2020;155(1):51-59. (Prospective cohort study; 183 patients)
  95. Joseph B, Aziz H, Pandit V, et al. Improving survival rates after civilian gunshot wounds to the brain. J Am Coll Surg. 2014;218(1):58-65. (Prospective study; 132 patients)
  96. Reginelli A, Pinto A, Russo A, et al. Sharp penetrating wounds: spectrum of imaging findings and legal aspects in the emergency setting. Radiol Med. 2015;120(9):856-865.(Review)
  97. Long B, April MD. Are patients with retained bullet fragments at greater risk for elevated blood lead levels? Ann Emerg Med. 2020;75(3):365-367. (Meta-analysis; 5 studies, 462 patients)
  98. Apte A, Bradford K, Dente C, et al. Lead toxicity from retained bullet fragments: a systematic review and meta-analysis. J Trauma Acute Care Surg. 2019;87(3):707-716.(Systematic review and meta-analysis; 2102 articles)

Bony Injury
Bony Injury
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No Bony Injury

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