Gun Shot Wound
Follow Up: Surgical Debridement

Thanks for all your great responses to the Gun Shot Wound Case Study from last week. Click on the LINK if you missed it…

I have posted several of your suggested treatment plans below. To summarize this patient’s course thus far: Since operative treatment was not an initial option, BID Acetic Acid bedside irrigations were performed, the site was packed with Acetic Acid soaked sponges, and the patient placed into posterior splint. At 4 days post injury, the trauma team returned to the OR and we were given the option to work on the foot at the same time. The bullet was located and excised from a plantar incision and the wound was explored.

A large curvilinear incision was extended from the 1st web space down to the site of the bullet excision. Abundant necrotic tissue was noted and this entire track was debrided. Grossly comminuted and contaminated distal phalanx of the hallux and 2nd metatarsal head were excised from the wound and the area was again packed open.

Wound VAC with silver impregnated sponge was then applied at bedside post op day 2. After approximately 1 week of VAC, the patient was brought back to OR for revision and closure of the wounds and is progressing unremarkably at this point…

Reader Responses

The 35 y/o male suffering multiple gunshot wounds would first need a vascular work up to assess the damage caused by the path of the bullet wound. With no palpable pulses an angiogram is indicated, with pulses, doppler measurements can still be taken to evaluate any occult damage. This should also be done frequently, to rule out any compartment syndrome of the foot and/or lower leg. Local wound care w/ copious lavage of wound daily w/ NS and sterile absorptive dressings will suffice, most likely, and a 1st or 2nd generation Cephalosporin IV for 2-3 days is recommended due to any debris existing in the permanent and temporary cavities left by the bullet. A posterior splint to protect the fractures and allow for them to heal properly is indicated as well.

Long term management will include probable surgical excision of the bullet if it bothers the patient or exhibits any signs of infection. Further neuro evaluation will be possible w/ a conscious pt to evaluate for any local nerve damage which can then be managed appropriately depending on the pathology. The patient would be weight bearing as tolerated w/ a surgical shoe for 4-6 wks, provided the wound is not on the plantar aspect.

David Ellenbogen, DPM
Metropolitan Hospital/NYCPM
Chief Resident
dellenb@nycpm.edu

1-If Pt. is undergoing anesthesia for E-Lap and kidney removal right away, so you will be able to sneak to the foot and do catheter lavage through the bullet's entrance and the take a culture, cover it not packed plus posterior splint inmobilization, and now wait and cover the patient with appropriate antibiotic in accordance with trauma team. The time for removal of bullet plantarly can wait undefined time.

But on the other hand if patient is driven directly to ICU then option ...

2- Just keep it simple, with some ankle block clean the wound of entrance, culture and INMOVBLIZATION with posterior splint

Totally agree that the bullet is not a priority in this case

Diego Adarve, DPM
Senior Podiatry Resident
Jackson South Community Hospital
orthopody@yahoo.com

I believe that the bullet has to come out sooner then later. It serves as a source of infection and needs to come out before serious problems develop. I know that Orthopedics commonly encounter cases like this and will perform things at bedside when the OR isn't available. So I would do an ankle block at bedside with a good PT block and remove the bullet and close or leave open depending on the state of the wound. Then I would put the pt in a posterior splint with NWB on the foot. As for the fractures I would let those sit until the patient is of the state that they can withstand surgery. With the massive injuries that they have sustained perhaps letting them heal as they are would be best for the patient.

Jason Bottoms, DPM
3rd year resident
Foot and Leg Healthcare group
Atlanta GA
drago642000@yahoo.com

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John Steinberg, DPM
Editor - PRESENT