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)