Review Question - QID 1687

The clinical presentation is consistent with a GSW with bowel perforation and a retained bullet in the vertebral body. Because the patient is neurologically intact broad-spectrum intravenous antibiotic coverage for 7 days is the most appropriate treatment.

Gunshot wounds to the spine present relatively little risk of infection in most cases. When there has been an injury to the small bowel, the risk of infection can be minimized with a 7-day course of broad-spectrum antibiotics. Indications for surgery include when a neurological deficit is present that correlates with imaging findings of neurological compression by the missile, or when the missile is in contact with the CSF posing a risk for metal toxicity.

Roffi et al performed a Level 4 study of 42 patients that sustained a gunshot wound that perforated the stomach or bowel and then entered the spinal column. They found that an extended regimen of broad spectrum antibiotics combined with bedrest appeared to significantly reduce the risk of spinal or paraspinal infection, whereas early bullet removal did not significantly prevent the occurrence of infection.

Velmahoos et al performed a Level 4 study including 24 patients that sustained a gunshot wound to the spine with associated colonic injury. They found that the incidence of sepsis was 8.4% (compared to 5% in non-bowel injuries) and concluded that retainment of the bullet did not increase the rate of sepsis.

Incorrect Answers:
Answer 1: The patient needs coverage for both Gram+ and Gram- organisms.
Answer 2: There are no indications for surgery at this point.
Answer 3: Antibiotics are indicated to decrease the risk of infection.
Answer 4: Intravenous antibiotic has been found to be more effective than oral antiobiotics.