Gunshot Wound Protocol Allows Early Discharge

ACEP News
December 2007
 

Michele G. Sullivan
Elsevier Global Medical News

NEW ORLEANS - Hemodynamically stable patients with isolated lower extremity gunshot wounds and no associated fractures can be safely discharged from the emergency department on the basis of a good ankle-brachial index, according to a review of more than 300 patients.

Dr. Javid Sadjadi of the University of California, San Francisco, said this algorithm had 100% specificity for ruling out other injuries, and carried a 98% negative predictive value--only 3 of 182 patients discharged from the ED had to be readmitted for wound complications.

The protocol study, presented at the annual clinical congress of the American College of Surgeons, analyzed 362 patients (mean age 26 years) admitted to the ED for an isolated gunshot wound to a lower extremity.

Patients who were admitted with signs of arterial hemorrhage, shock, distal ischemia, or significant vascular injury were taken to the operating department for exploration and treatment, or received angiography to determine the level of vascular injury. Those who met the protocol inclusion criteria (182) were discharged from the ED after an average of 9 hours. All patients were hemodynamically stable and had no physical exam findings indicating vascular injury, no fracture, and an ankle-brachial index of 0.90 or greater compared with the uninjured leg.

On follow-up, there were no cases of ischemia or limb loss. Three patients returned with complications. Two patients had superficial wound infections that were treated locally and with intravenous antibiotics. Another patient was admitted with delayed compartment syndrome secondary to pseudoaneurysm of a branch of the popliteal artery. This patient received embolization; after treatment, he retained full function of the leg.

The early-discharge protocol saved money, Dr. Sadjadi said. The cost of treating the 182 patients was $180,600. If all these patients had received noninvasive ultrasound exams, the cost would have risen to $289,000, and if they had received arteriograms, the cost would have been $325,400.

"Early discharge not only saves resources but results in direct cost savings to our medical center and to our county," Dr. Sadjadi said, noting that only about 10% of the patients in the study carried private health insurance.

The protocol's weak spot is the inability of the ankle-brachial index to identify a possible pseudoaneurysm, Dr. Sadjadi said.

"You may have a pseudoaneurysm of an artery but intact flow to the foot, and thus the AB index would miss this complication," he noted.

To address this weakness, the protocol has been modified. "We now include duplex ultrasound imaging on any stable patients with good AB index who have a wound track that might place the trajectory of the missile in proximity to a vessel," he said.

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