GUNSHOT INJURY
A 16-year-old male is brought to the emergency department after a reported gunshot injury. He has a wound to the forearm that has been dressed and splinted by the ambulance service.
- Describe your management of this patient in the emergency department.
This patient would be received in the emergency department by the trauma team and would be treated along ATLS guidelines. The patient should be fully exposed to ensure that any other occult injuries are detected and entry or exit wounds can be clearly identified. The obvious wound should be inspected for signs of obvious major or catastrophic haemorrhage which should be controlled with direct pressure, dressings or a tourniquet if necessary. Any field tourniquets should be exchanged for pneumatic tourniquets. Wounds should be photographed before they are redressed with simple saline-soaked gauze dressings and any obvious contamination removed at the time.
A careful assessment of the neurovascular status is made, the patient is given analgesia as well as prophylactic antibiotics and tetanus immunoglobulin and then the limb is splinted in an above elbow backslab. I would then arrange plain radiographs to include the elbow and wrist. I would complete the assessment with a careful secondary survey. General Medical Council guidance is that all gunshot injuries should be notified to the police.
- These are the radiographs for this patient. How would you propose to treat this injury?
These are AP and lateral radiographs of the left forearm which show a segmental fracture of the ulna and some foreign material likely to be shrapnel. The clinical photograph shows a wound over the forearm. The degree of soft tissue injury will relate to the energy or velocity of the gunshot and there is the potential for significant injury, cavitation and the introduction of foreign matter into the wound with a high-energy injury.
I would advise operative treatment and would undertake a wound debridement, extending the skin wound longitudinally and excising any necrotic or questionable tissue. I would undertake this with a senior plastic surgeon in attendance. I would send multiple samples for microbiology study, remove any foreign material and shrapnel and irrigate the wound thoroughly with 9 litres of warmed saline, ensuring that I had explored the extent of the injury track. The debridement would include all tissue layers down to and including bone. Following debridement, I would determine whether to apply a plaster cast, external fixator or temporising intramedullary wire in order to confer temporary bony stability. With the plastic surgeon, I would consider whether the wound could and should be primarily closed following debridement or whether graft or flap coverage or even delayed staged treatment would be more appropriate.
I would continue intravenous antibiotics for 72 hours or until initial microbiology results are available for contaminated wounds but would otherwise stop antibiotics following wound closure or coverage. For contaminated wounds or those where it is judged that staged treatment is most appropriate, I would return to the operating theatre for a second look and further debridement with the potential for wound closure or coverage after 48 hours.