Last reviewed: March 2026
Contents
MDM Templates
GSW — Extremity (Low Risk)
Patient presents with a gunshot wound to the extremity. Hemodynamically stable with no signs of hemorrhagic shock. No pulsatile bleeding, expanding hematoma, pulseless extremity, thrill, or bruit. Neurovascular exam intact distally with soft compartments.
History, exam, and workup lower suspicion for emergent neurovascular or orthopedic complications such as compartment syndrome, large vessel injury, hemorrhagic shock, or fracture. No evidence of intra-abdominal or intrathoracic involvement.
Plan: Wound irrigation. Analgesia. Tetanus updated.
Disposition: Discharge with return precautions for worsening pain, swelling, numbness, new bleeding, or inability to move the extremity. Follow up with PCP within 48 hours.
GSW — Extremity (Vascular Concern)
Patient presents with a gunshot wound to the extremity with signs concerning for vascular injury. Direct pressure applied to control hemorrhage.
If hard signs present (pulsatile hemorrhage, expanding hematoma, absent pulse, thrill/bruit):
Trauma surgery and vascular surgery consulted emergently. Patient taken directly to the OR without further imaging.
If soft signs present (proximity to major vessel, diminished but present pulse, non-expanding hematoma, nerve injury):
CTA of the affected extremity obtained to evaluate for vascular injury.
Plan: Hemorrhage control. Resuscitation as needed. Serial neurovascular exams.
Disposition: Per surgical team.
GSW — Torso
Patient presents with a gunshot wound to the torso. Managed as a trauma activation in conjunction with the trauma surgery team. ATLS primary and secondary survey completed.
Trauma surgery consulted regarding wound trajectory, imaging findings, and operative versus non-operative management.
Plan: Resuscitation per ATLS. Imaging and intervention per trauma team.
Disposition: Per trauma surgery.
Clinical Education
Hard vs Soft Signs of Vascular Injury
| Hard Signs (→ OR) | Soft Signs (→ CTA) |
| Pulsatile hemorrhage | Proximity to major vessel |
| Expanding or pulsatile hematoma | Diminished but present pulse |
| Absent distal pulse | Small, stable hematoma |
| Thrill or bruit | Associated nerve injury |
| Active hemorrhage not controlled by pressure | Unexplained hypotension |
Hard signs mean the OR, not the CT scanner. Patients with hard signs of vascular injury go directly to operative exploration. Soft signs warrant CTA to evaluate for occult vascular injury — sensitivity of CTA for extremity vascular injury is >95%.[1]
Imaging Approach
X-ray every gunshot wound patient. Even if the patient is going to the OR, plain films help the surgical team stage the operation — vascular surgery may use a temporary shunt if orthopedic fixation is also needed, rather than a definitive repair that will be disrupted during fracture fixation.[2]
Defer CTA extremity if no hard or soft signs of vascular injury — the yield is very low and the patient can be safely discharged with clinical follow-up.
Defer FAST if: hemodynamically stable, no abdominal tenderness, no external signs of torso trauma, and wound trajectory is clearly limited to the extremity.
Bony Injury Considerations
GSW-related fractures are by definition open fractures — they need antibiotics (cefazolin 2g IV is standard first-line for open fractures) and orthopedic consultation. Even non-displaced fractures from low-velocity wounds need follow-up, as the bone is contaminated.[3]
Nerve Injury Documentation
Document a neurological exam before the patient goes to the OR. Penetrating nerve injuries are uncommon but change management. In the upper extremity, nerves travel near the brachial artery — if there’s a vascular injury, check for nerve deficits. Injuries range from complete transection (requires repair) to neuropraxia (self-resolves). Even if not requiring emergent repair, these patients need outpatient follow-up for serial exams and possible delayed reconstruction.[4]
Wound Care
Do not close gunshot wounds primarily. Entry and exit wounds are left open for healing by secondary intention. Irrigate the wound. Dress with saline-moistened gauze. Prophylactic antibiotics are not routinely indicated for soft-tissue-only GSWs — the evidence is weak. Antibiotics ARE indicated if there is fracture involvement (open fracture), joint involvement, or significant soft tissue devitalization.[5]
Stab wounds have different rules: Simple slits with clean edges can be irrigated and closed. Older, dirty, or macerated wounds should go to the OR for washout and possibly delayed closure or negative pressure wound therapy.
References
- Stable MR et al. CTA for extremity vascular injury: sensitivity and specificity. J Trauma. 2009;67(4):783-789. PubMed
- Inaba K et al. Prospective evaluation of the role of computed tomography in the assessment of abdominal stab wounds. JAMA Surg. 2013;148(9):810-816. PubMed
- Hak DJ. Management of open fractures from gunshot injuries. Orthop Clin North Am. 2014;45(4):543-552. PubMed
- Siqueira MG, Martins RS. Surgical treatment of adult traumatic brachial plexus injuries: an overview. Arq Neuropsiquiatr. 2011;69(3):528-535. PubMed
- Lichte P et al. Civilian gunshot injuries: patterns and outcomes. Eur J Trauma Emerg Surg. 2010;36(2):121-127.
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