Initial evaluation and management of abdominal gunshot wounds in adults
- Christopher Colwell, MD
Christopher Colwell, MD
- Chief of Emergency Medicine
- Zuckerberg San Francisco General Hospital and Trauma Center
- Professor and Vice-Chair, Department of Emergency Medicine
- University of California at San Francisco School of Medicine
- Ernest E Moore, MD
Ernest E Moore, MD
- Vice Chairman for Research
- Professor of Surgery
- University of Colorado Denver
While in the past abdominal gunshot wounds (GSWs) often mandated exploratory laparotomy, with the advent of newer diagnostic and therapeutic modalities, and the ability for noninvasive critical care monitoring, fewer patients cross the operating room threshold.
This topic review will discuss the evaluation and management of abdominal GSWs. Abdominal stab wounds, blunt abdominal trauma, and other aspects of general trauma management are discussed separately. (See "Initial evaluation and management of abdominal stab wounds in adults" and "Initial evaluation and management of blunt abdominal trauma in adults" and "Initial management of trauma in adults".)
Although encountered less frequently than stab wounds, gunshot wounds (GSWs) carry higher mortality due in large part to the greater energy transmitted to tissues [1,2]. Abdominal injury from GSWs accounts for up to 90 percent of the mortality associated with penetrating abdominal injuries. Although data is limited, the mortality rate for isolated abdominal GSWs is reported to be approximately 7 percent. Approximately 25 percent of such injuries may be managed non-operatively in appropriate settings. The small bowel is the organ most frequently injured, followed by the colon and liver. (See 'Selective nonoperative management' below.)
MECHANISMS OF INJURY
Ballistic wounds can occur from a variety of missiles including bullets, grenades, flying glass, and objects launched by lawn mowers or severe weather. Among such injuries, gunshot wounds (GSWs) to the abdomen most often require operative intervention.
The velocity of the missile and its distance from the patient are important factors in determining the extent of injury. Medium and high-velocity weapons (such as AK 47s) also cause injury by opening and closing tissue with such force as to create a wave of energy that can damage intraperitoneal structures, despite entirely extraperitoneal tracking of the missile. Projectiles from medium velocity weapons travel 335 to 610 m/second, or 1100 to 2000 feet/second, while projectiles from high-velocity weapons travel >610 m/second, or >2000 feet/second.
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- MECHANISMS OF INJURY
- ANATOMIC ZONES
- METHODS OF EVALUATION
- Initial assessment
- Local wound exploration
- Plain radiographs
- Computed tomography (CT)
- Diagnostic peritoneal lavage
- Diagnostic laparoscopy
- Indications for laparotomy and general approach to management
- Laboratory studies
- Peritoneal injury
- Selective nonoperative management
- Prophylactic antibiotics
- SPECIAL CONSIDERATIONS
- Flank and back
- Gunshot wounds in pregnancy
- Patients on anticoagulants
- Law enforcement and social service issues
- SUMMARY AND RECOMMENDATIONS