Review Question - QID 4553

Based on the clinical presentation, this patient should be treated initially with empiric antibiotic therapy and observation.

The available literature shows that transabdominal GSW with intra-articular contamination should be urgently débrided and irrigated; extra-articular transabdominal GSW with stable fracture patterns may be managed with observation and empiric antibiotics. Bullets lodged in intra-articular locations should be removed, but retained bullets in other anatomic locations do not necessarily warrant removal.

Watters et al. retrospectively collected Information regarding surgical débridement of pelvis low velocity gunshot wounds, retained foreign bodies, and/or concomitant gastrointestinal (GI) injury was analyzed for relationships of such events to infection rate in 56 patients. The authors found that there was no increased incidence of infection in the absence of aggressive surgical débridement of pelvis gunshot wounds. The study also demonstrated that retained bullets and bullet fragments did not increase the risk of infection, even after penetrating the GI tract organs.

Zura et al. completed a review article on the treatment of gunshot wounds to the hip and pelvis. The authors state that antibiotic treatment usually is indicated for patients with gunshot wounds to the pelvis, but is controversial in patients with low-energy wounds. Furthermore they state that fractures are treated based on their stability and wound care should be determined by the personality of the injury, and not solely based on the velocity of the missile.

Miller et al. completed a recent review article on transabdominal gunshot wounds to the hip and pelvis. They state that extra-articular transabdominal GSW with stable fracture patterns may be managed with observation and empiric antibiotics.

Incorrect Answers:
Answer 1: Immediate exploratory laparotomy would be indicated in the setting of persistent hemodynamic instability or positive peritoneal signs.
Answer 2: There is no evidence that bullet removal is necessary when it is in an extra-articular location. Furthermore the bony injury is stable, and does not warrant fixation.
Answer 3: Immediate surgical debridement is not necessary without intra-articular involvement or severe soft tissue injury.
Answer 5: Sigmoidoscopy would be necessary if occult blood was noted on rectal examination or if the bullet crossed the midline below the pelvic brim.