General assessment

The assessment of patients injured by ballistic trauma includes resuscitation, medical history, physical examination, radiographs, and other diagnostic tests. Advanced Trauma Life Support protocols are followed as in blunt trauma, but several additional concerns must be addressed. The time from injury, the type of weapon, the distance between the weapon and victim, and the amount of blood at the scene are important facts to attain. Low-velocity bullets cause organ injury within their anatomical path. High-velocity missiles, shotgun blasts, and bombs create additional injury via blast injury and cavitation. Complete patient exposure allows identification of all wounds and predicts the number of body cavities violated. Pulsatile hemorrhage is immediately controlled with pressure from a gloved finger or hand. Two large-bore (16 gage or greater) peripheral intravenous cannulas are placed in the upper extremity in patients with abdominal or lower extremity wounds, and in the lower extremities in patients with missile injuries to the upper extremities or subclavicular areas. Blood is obtained for type- and cross-matching. Tetanus prophylaxis and appropriate antibiotics are administered. Blood found in endotracheal tubes, nasogastric tubes, bladder catheters, the rectum, or the vagina imply internal organ damage. Extremity fractures are immobilized and peripheral pulses are noted. Ambient temperatures are elevated, the patient is covered, and intravenous fluids are warmed in order to avert hypothermia. Frequent monitoring of vital signs gages the effectiveness of the resuscitation. In general, patients with unstable vital signs require immediate surgical exploration, while patients with stable vital signs may benefit from additional diagnostic maneuvers prior to operation.

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