Gunshot Wound… November 21, 2011
Posted by ebmedicine in Traumatic Emergencies.trackback
A 25-year-old man presents to the ED via ambulance after sustaining a single gunshot wound to the upper abdomen. There is no apparent exit wound. He is awake, in obvious pain and distress, with labored spontaneous breathing. He was reportedly shot with a handgun at close range, and there was significant blood loss at the scene. He has decreased breath sounds on the left side and a mildly tender abdomen with a small wound over the left anterior lower chest. A FAST examination shows no free fluid in the abdomen and no pericardial effusion. A left-sided chest tube is placed, with 200 mL of blood out immediately, and subsequent chest x-ray shows a right hemothorax with a bullet lodged in the left lower lobe.
Are additional tests needed before this patient arrives for surgery? What is this patient’s likely outcome?
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the patient has a gun shot injury involving both the lungs (decreased breath sounds on right & hemothorax bilateral as there is blood coloured drain in the left chest tube)
the investigations required include Hb/CBC, blood grouping and cross matched blood
as there is suspected injury to the mediatinal vessels so he would need exploration of the thoracic cavity.
needless to say vital monitoring is crucial to warrant urgent resuscitation steps as needed
the patient has gunshot that transfer the medistinal and lower chest,so my be involve diaphram and abdominal so only investigation required cbc and blood group and cross matching if unstable.
if stable chest and abdominalst scan is advice after bilateral chest tubes
he was shot in an area prone to double penetrating injuries, abdomen and chest. The chest consecuences are evident but the abdomen should be investigated. because one single fast doesn’t tell the whole story.
Male with gsw to lower left chest reulting in hemothorax. Chest tubes already in place. He will need cbc, type/cross, pt/inr, exploaratory of thorax, and maybe abdomen as he could have spleenic injury not caught on FAST exam. If pt remains stable, should have a fairly good outcome.
Major Vessel injury> Immediate surgery needed/ guarded prognosis
Patient has bilateral hemothorax with probability of medaistinal vessel injury as well, needs urgent surgical intervention , investigation needs CBC, HB Cross matching & typing.
Bilateral hemo/pneumothorax with possible aorta/esphagus/liver/spleen injury. I would not order further tests if OR is available – pt must go straight to OR for definitive exploration and repair. If time allows, I would place right chest tube, transfuse 4 units of PRBC (if VSS) and more if not. Consider early intubation
The patient must be triage as critical and trauma team must be activated. He suffered from bilateral chest – massive hemothorax, injury with possibility of abdominal diaphragmatic injury and spine injury. He should undergo emergency exploratory thoracothomy for immediate bleeding controlled and laparotomy and proceed to look for any other associated injury.
since the 200ml is not that significant ,patient has a little time for more specific dg with a ct for assessment of the indication and approach
Tests required are 1.Crossmatching blood for surgery 2.possible plain radiograph to see if another bullet outside the chest
The outcome will be good
There should not be any further investigation and the patient should be rushed to theatre for exploration, removal of bullet and stop bleeding. I think the prognosis is good as long as urgent surgical interference is done and homeostasis is maintained
this patient have a trasmediastinal shot, is obvious about the left hemothorax, but, I m not trust about the right hemothorax, the pericardium is clear, and the abdomen is clear, but there is a big silent pal that we have not check yet, so I ask for a thoracic tomographic scan if the stability of the patient allowed it, looking for a aortic laceration because the chest x-ray is not sensible or especific, I consider the imaginology, but really that could be checked on the surgery, so I ask to my surgeon first if we can to go to take that test because the time is gold, thanks for your atention
after resustation of this pt by bilatral chest tube and blood transfusion if he was stablized we can send him for ches and abdominal CT scan to look for pericardium and mediastinal content injury ,outcome depend up to extent of organ injury.
Additional test needed are type and cross match for blood products.
Coagulation studies for evaluation of bleeding disorders.
Comprehensive Metabolic lab test for evaluation of diabetes, kidney or livers disorders. These test may be ordered while he is on his way to surgery. He should not wait in the ED for the results.
He will have an excellent outcome with proper surgery and medical management of any preexisting medical issues.