Surgery

27 year-old male with gunshot wound to LUE

Brooklyn Fillinger on Jan 29, 2018 - University of Michigan

A 27 year-old male presents to the emergency department following gunshot wound to the left upper extremity sustained one hour ago while fleeing from a police officer. He is awake, hemodynamically stable, and in a moderate amount of pain, describing a throbbing pain rated 7/10.

Which of the following questions are important to ask during your medical history? Check all that apply.

Select all that apply
Expand all answers
Medication history
Yes! Medication history is necessary in this case. Pay special attention to whether or not the patient is taking any medications that may effect the coagulation cascade, including aspiring, Plavix, and warfarin. Complete list of medications is necessary so that you will know if any interactions will exist between his current medications and those you may prescribe. This patient takes no medications..


Social history
Absolutely. It is prudent to know if your patient is an IV drug user, especially since you will likely be holding pressure on the wound and you should be aware of the potential presence of needles! You also want to know about substance use history to be on the lookout for withdrawals. The patient has no relevant social history.


Past medical history
Yes! This is always helpful to know. The patient gets rare panic attacks but is not treated for them.


Family history
Correct. In this case, when the bleeding has been controlled and when appropriate. This could be helpful to see about history of aneurysms, bleeding disorders, and clotting disorders. There is no relevant family history.


What physical exam maneuvers do you want to perform for this patient? Check all that apply.

Select all that apply
Expand all answers
Pulse examination
Absolutely! The most important part of the physical exam for this patient is to make sure that pulses are present, especially distal to the injury site. The results of your exam will largely determine treatment. Pulses are full and equal bilaterally at DP, PT, and R radial artery. The L radial pulse is not palpable and the L brachial artery pulse cannot be found, as the L brachial artery is the site of injury).


Heart exam
While not necessary to the treatment of the patient's gunshot wound, this is a good idea. RRR observed.


Abdominal exam
Correct. While not necessarily intuitive, you want to make sure there are no additional wounds in the abdomen that need to be addressed, especially because patients can "hide" a lot of blood in the abdomen. There are no abdominal injuries or tenderness.


Inspection of injury site
Yes. Look for entry and exit wounds, as well as extent of damage. Gunshot wound seen at L brachial artery between the two heads of the L biceps. There is a clear exit injury posterior to the entry site. No bullet is present within the wound. You notice that the L brachial artery is exposed to air and that both the long and short heads of the L biceps are severed within the muscle bellies. Hard signs of arterial injury include the following: ●Active hemorrhage ●Expanding or pulsatile hematoma ●Bruit or thrill over wound ●Absent distal pulses ●Extremity ischemia (pain, pallor, paralysis, cool to touch)


While the patient is hemodynamically stabe, you are concerned that you cannot find a palpable L radial pulse. You decide to consult the vascular surgery team. On their examination, they are able to find a doppler signal at the L radial artery, which provides them with reassurance that limb loss is not an immediate threat. However, they are concerned because the L brachial artery is exposed to air, which studies have shown may cause vascular desiccation. 

What is the next best step in caring for this patient?

Select all that apply
Expand all answers
CT angiogram of upper extremities
No. This is not indicated because the patient has a Doppler signal distal to the site of injury, so it is unlikely that there is significant bleeding which was not seen on exam.


LUE ultrasound
Not so much. This wouldn't provide much additional information in the acute setting because a distal Doppler signal was found. This would provide more information if performed intraoperatively, where the probe can be placed directly on the artery.


Take patient to OR for washout and further evaluation
Yes! The area should be further evaluated in the operating room for a few reasons: 1. The artery is exposed to air, which can cause dessication 2. Intimal injury and arterial flow should be evaluated via intraop ultrasound 3. The wound should be washout out- likely with antibiotics 4. There is possible muscle damage that needs to be repaired 5. The site should be evaluated for the need of bypass around the site of injury


LUE x-ray
This is likely a good idea (and was probably done by the ED prior to surgical consult), but is not relevant to the vascular injury. It is also important to prioritize the patient's injuries. Any vascular injuries should be fixed prior to orthopedic injuries because once the arm is casted (if applicable), it is more difficult to evaluate the vasculature postoperatively.


Clean the wound, close the laceration, place dressing on the area, and send the patient home with a small dose of pain medication
This is not the best course of action because there is a pulse difference between the R and L radial arteries, so the vasculature of the LUE should be evaluated further to prevent complications such as thrombus formation and/ or limb ischemia.


In the OR, the surgeon notices the same gross findings reported by the ED. The L brachial artery is intact on detailed examination. Intraopertive ultrasound demonstrates arterial flow both proximal and distal to the wound. There is one location on the L brachial artery; however, that demonstrates turbulent flow on ultrasound. The surgeon suspects mild intimal injury. Orthopedic surgery is consulted intraoperatively to evaluate the L biceps and L humerus. No muscle repair is needed and no humeral fracture identified. Vascular surgery plans washout with antibiotic solution and loose skin closure for protection of the artery from air.

What should the patient be prescribed for treatment of intimal injury?

Expand all answers
Surgical revascularization of the brachial artery
This is not necessary, as there is still adequate blood flow through the artery


Amputation of LUE
No. Please don't do this.


Warfarin with lovenox bridge
While this would prevent thrombus formation that can result from intimal trauma, it is overkill


Baby aspirin daily for 6 months
Yes! 81 mg ASA daily can prevent thrombus formation from intimal injury!


Heparin drip
This is not a practical long-term therapy and is overkill for this patient


Clinic follow-up in 3 weeks
While it is a good idea to follow-up with this patient, he also needs treatment with ASA to prevent complications of intimal injury


A 27 year-old male presents to the emergency department following gunshot wound to the left upper extremity sustained one hour ago while fleeing from a police officer. He is awake, hemodynamically stable, and in a moderate amount of pain, describing a throbbing pain rated 7/10.

Which of the following questions are important to ask during your medical history? Check all that apply.

Select all that apply
Expand all answers
Medication history
Yes! Medication history is necessary in this case. Pay special attention to whether or not the patient is taking any medications that may effect the coagulation cascade, including aspiring, Plavix, and warfarin. Complete list of medications is necessary so that you will know if any interactions will exist between his current medications and those you may prescribe. This patient takes no medications..


Social history
Absolutely. It is prudent to know if your patient is an IV drug user, especially since you will likely be holding pressure on the wound and you should be aware of the potential presence of needles! You also want to know about substance use history to be on the lookout for withdrawals. The patient has no relevant social history.


Past medical history
Yes! This is always helpful to know. The patient gets rare panic attacks but is not treated for them.


Family history
Correct. In this case, when the bleeding has been controlled and when appropriate. This could be helpful to see about history of aneurysms, bleeding disorders, and clotting disorders. There is no relevant family history.


What physical exam maneuvers do you want to perform for this patient? Check all that apply.

Select all that apply
Expand all answers
Pulse examination
Absolutely! The most important part of the physical exam for this patient is to make sure that pulses are present, especially distal to the injury site. The results of your exam will largely determine treatment. Pulses are full and equal bilaterally at DP, PT, and R radial artery. The L radial pulse is not palpable and the L brachial artery pulse cannot be found, as the L brachial artery is the site of injury).


Heart exam
While not necessary to the treatment of the patient's gunshot wound, this is a good idea. RRR observed.


Abdominal exam
Correct. While not necessarily intuitive, you want to make sure there are no additional wounds in the abdomen that need to be addressed, especially because patients can "hide" a lot of blood in the abdomen. There are no abdominal injuries or tenderness.


Inspection of injury site
Yes. Look for entry and exit wounds, as well as extent of damage. Gunshot wound seen at L brachial artery between the two heads of the L biceps. There is a clear exit injury posterior to the entry site. No bullet is present within the wound. You notice that the L brachial artery is exposed to air and that both the long and short heads of the L biceps are severed within the muscle bellies. Hard signs of arterial injury include the following: ●Active hemorrhage ●Expanding or pulsatile hematoma ●Bruit or thrill over wound ●Absent distal pulses ●Extremity ischemia (pain, pallor, paralysis, cool to touch)


While the patient is hemodynamically stabe, you are concerned that you cannot find a palpable L radial pulse. You decide to consult the vascular surgery team. On their examination, they are able to find a doppler signal at the L radial artery, which provides them with reassurance that limb loss is not an immediate threat. However, they are concerned because the L brachial artery is exposed to air, which studies have shown may cause vascular desiccation. 

What is the next best step in caring for this patient?

Select all that apply
Expand all answers
CT angiogram of upper extremities
No. This is not indicated because the patient has a Doppler signal distal to the site of injury, so it is unlikely that there is significant bleeding which was not seen on exam.


LUE ultrasound
Not so much. This wouldn't provide much additional information in the acute setting because a distal Doppler signal was found. This would provide more information if performed intraoperatively, where the probe can be placed directly on the artery.


Take patient to OR for washout and further evaluation
Yes! The area should be further evaluated in the operating room for a few reasons: 1. The artery is exposed to air, which can cause dessication 2. Intimal injury and arterial flow should be evaluated via intraop ultrasound 3. The wound should be washout out- likely with antibiotics 4. There is possible muscle damage that needs to be repaired 5. The site should be evaluated for the need of bypass around the site of injury


LUE x-ray
This is likely a good idea (and was probably done by the ED prior to surgical consult), but is not relevant to the vascular injury. It is also important to prioritize the patient's injuries. Any vascular injuries should be fixed prior to orthopedic injuries because once the arm is casted (if applicable), it is more difficult to evaluate the vasculature postoperatively.


Clean the wound, close the laceration, place dressing on the area, and send the patient home with a small dose of pain medication
This is not the best course of action because there is a pulse difference between the R and L radial arteries, so the vasculature of the LUE should be evaluated further to prevent complications such as thrombus formation and/ or limb ischemia.


In the OR, the surgeon notices the same gross findings reported by the ED. The L brachial artery is intact on detailed examination. Intraopertive ultrasound demonstrates arterial flow both proximal and distal to the wound. There is one location on the L brachial artery; however, that demonstrates turbulent flow on ultrasound. The surgeon suspects mild intimal injury. Orthopedic surgery is consulted intraoperatively to evaluate the L biceps and L humerus. No muscle repair is needed and no humeral fracture identified. Vascular surgery plans washout with antibiotic solution and loose skin closure for protection of the artery from air.

What should the patient be prescribed for treatment of intimal injury?

Expand all answers
Surgical revascularization of the brachial artery
This is not necessary, as there is still adequate blood flow through the artery


Amputation of LUE
No. Please don't do this.


Warfarin with lovenox bridge
While this would prevent thrombus formation that can result from intimal trauma, it is overkill


Baby aspirin daily for 6 months
Yes! 81 mg ASA daily can prevent thrombus formation from intimal injury!


Heparin drip
This is not a practical long-term therapy and is overkill for this patient


Clinic follow-up in 3 weeks
While it is a good idea to follow-up with this patient, he also needs treatment with ASA to prevent complications of intimal injury


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