Initial assessment for a<unk>  is approached in the same way as other acute trauma using the advanced trauma life support (ATLS) protocol. These include: * A) Airway - Assess and protect airway and potentially the cervical spine * B) Breathing - Maintain adequate ventilation and oxygenation * C) Circulation - Assess for and control bleeding to maintain organ perfusion including focused assessment with sonography for trauma (FAST) * D) Disability - Perform basic neurological exam including Glasgow Coma Scale (GCS) * E) Exposure - Expose entire body and search for any missed injuries, entry points, and exit points while maintaining body temperature Depending on the extent of injury, management can range from urgent surgical intervention to observation. As such, any history from the scene such as gun type, shots fired, shot direction and distance, blood loss on scene, and pre-hospital vitals signs can be very helpful in directing management. Unstable people with signs of bleeding that cannot be controlled during the initial evaluation require immediate surgical exploration in the operating room. Otherwise, management protocols are generally dictated by anatomic entry point and anticipated trajectory. Neck Penetrating neck injury protocol. A<unk>  to the neck can be particularly dangerous because of the high number of vital anatomical structures contained within a small space. The neck contains the larynx, trachea, pharynx, esophagus, vasculature (carotid, subclavian, and vertebral arteries; jugular, brachiocephalic, and vertebral veins; thyroid vessels), and nervous system anatomy (spinal cord, cranial nerves, peripheral nerves, sympathetic chain, brachial plexus).<unk> s to the neck can thus cause severe bleeding, airway compromise, and nervous system injury. Initial assessment of a<unk>  to the neck involves non-probing inspection of whether the injury is a penetrating neck injury (PNI), classified by violation of the platysma muscle. If the platysma is intact, the<unk>  is considered superficial and only requires local<unk>  care. If the injury is a PNI, surgery should be consulted immediately while the case is being managed. Of note,<unk> s should not be explored on the field or in the emergency department given the risk of exacerbating the<unk> . Due to the advances in diagnostic imaging, management of PNI has been shifting from a "zone-based" approach, which uses anatomical site of injury to guide decisions, to a "no-zone" approach which uses a symptom-based algorithm. The no-zone approach uses a hard signs and imaging system to guide next steps. Hard signs include airway compromise, unresponsive shock, diminished pulses, uncontrolled bleeding, expanding hematoma, bruits/thrill, air bubbling from<unk>  or extensive subcutaneous air, stridor/hoarseness, neurological deficits. If any hard signs are present, immediate surgical exploration and repair is pursued alongside airway and bleeding control. If there are no hard signs, the person receives a multi-detector CT angiography for better diagnosis. A directed angiography or endoscopy may be warranted in a high-risk trajectory for the<unk> . A positive finding on CT leads to operative exploration. If negative, the person may be observed with local<unk>  care. Chest Important anatomy in the chest includes the chest wall, ribs, spine, spinal cord, intercostal neurovascular bundles, lungs, bronchi, heart, aorta, major vessels, esophagus, thoracic duct, and diaphragm.<unk> s to the chest can thus cause severe bleeding (hemothorax), respiratory compromise (pneumothorax, hemothorax, pulmonary contusion, tracheobronchial injury), cardiac injury (pericardial tamponade), esophageal injury, and nervous system injury. Initial workup as outlined in the Workup section is particularly important with<unk> s to the chest because of the high risk for direct injury to the lungs, heart, and major vessels. Important notes for the initial workup specific for chest injuries are as follows. In people with pericardial tamponade or tension pneumothorax, the chest should be evacuated or decompressed if possible prior to attempting tracheal intubation because the positive pressure ventilation can cause hypotention or cardiovascular collapse. Those with signs of a tension pneumothorax (asymmetric breathing, unstable blood flow, respiratory distress) should immediately receive a chest tube (> French 36) or needle decompression if chest tube placement is delayed. FAST exam should include extended views into the chest to evaluate for hemopericardium, pneumothorax, hemothorax, and peritoneal fluid. Those with cardiac tamponade, uncontrolled bleeding, or a persistent air leak from a chest tube all require surgery. Cardiac tamponade can be identified on FAST exam. Blood loss warranting surgery is 1–1.5 L of immediate chest tube drainage or ongoing bleeding of 200-300 mL/hr. Persistent air leak is suggestive of tracheobronchial injury which will not heal without surgical intervention. Depending on the severity of the person's condition and if cardiac arrest is recent or imminent, the person may require surgical intervention in the emergency department, otherwise known as an emergency department thoracotomy (EDT). However, not all<unk>  to the chest require surgery. Asymptomatic people with a normal chest X-ray can be observed with a repeat exam and imaging after 6 hours to ensure no delayed development of pneumothorax or hemothorax. If a person only has a pneumothorax or hemothorax, a chest tube is usually sufficient for management unless there is large volume bleeding or persistent air leak as noted above. Additional imaging after initial chest X-ray and ultrasound can be useful in guiding next steps for stable people. Common imaging modalities include chest CT, formal echocardiography, angiography, esophagoscopy, esophagography, and bronchoscopy depending on the signs and symptoms. Abdomen Abdominal<unk>  Important anatomy in the abdomen includes the stomach, small bowel, colon, liver, spleen, pancreas, kidneys, spine, diaphragm, descending aorta, and other abdominal vessels and nerves.<unk> s to the abdomen can thus cause severe bleeding, release of bowel contents, peritonitis, organ rupture, respiratory compromise, and neurological deficits. The most important initial evaluation of a<unk>  to the abdomen is whether there is uncontrolled bleeding, inflammation of the peritoneum, or spillage of bowel contents. If any of these are present, the person should be transferred immediately to the operating room for laparotomy. If it is difficult to evaluate for those indications because the person is unresponsive or incomprehensible, it is up to the surgeon's discretion whether to pursue laparotomy, exploratory laparoscopy, or alternative investigative tools. Although all people with abdominal<unk> s were taken to the operating room in the past, practice has shifted in recent years with the advances in imaging to non-operative approaches in more stable people. If the person's vital signs are stable without indication for immediate surgery, imaging is done to determine the extent of injury. Ultrasound (FAST) and help identify intra-abdominal bleeding and X-rays can help determine bullet trajectory and fragmentation. However, the best and preferred mode of imaging is high-resolution multi-detector CT (MDCT) with IV, oral, and sometimes rectal contrast. Severity of injury<unk>  on imaging will determine whether the surgeon takes an operative or close observational approach. Diagnostic peritoneal lavage (DPL) has become largely obsolete with the advances in MDCT, with use limited to centers without access to CT to guide requirement for urgent transfer for operation. Extremities Acute penetrating trauma from a close-range shotgun blast injury to knee. Birdshot pellets are visible in the<unk> , within the shattered patella. The powder wad from the shotgun shell has been extracted from the<unk> , and is visible at the upper right of the image. The four main components of extremities are bones, vessels, nerves, and soft tissues.<unk> s can thus cause severe bleeding, fractures, nerve deficits, and soft tissue damage. The Mangled Extremity Severity Score (MESS) is used to classify the severity of injury and evaluates for severity of skeletal and/or soft tissue injury, limb ischemia, shock, and age. Depending on the extent of injury, management can range from superficial<unk>  care to limb amputation. Vital sign stability and vascular assessment are the most important determinants of management in extremity injuries. As with other traumatic cases, those with uncontrolled bleeding require immediate surgical intervention. If surgical intervention is not readily available and direct pressure is insufficient to control bleeding, tourniquets or direct clamping of visible vessels may be used temporarily to slow active bleeding. People with hard signs of vascular injury also require immediate surgical intervention. Hard signs include active bleeding, expanding or pulsatile hematoma, bruit/thrill, absent distal pulses and signs of extremity ischemia. For stable people without hard signs of vascular injury, an injured extremity index (IEI) should be calculated by comparing the blood pressure in the injured limb compared to an uninjured limb in order to further evaluate for potential vascular injury. If the IEI or clinical signs are suggestive of vascular injury, the person may undergo surgery or receive further imaging including CT angiography or conventional arteriography. In addition to vascular management, people must be evaluated for bone, soft tissue, and nerve injury. Plain films can be used for fractures alongside CTs for soft tissue assessment. Fractures must be debrided and stabilized, nerves repaired when possible, and soft tissue debrided and covered. This process can often require multiple procedures over time depending on the severity of injury.
Gunshot wound
Centipede bite
Stingray injury
Dog bite
Cat bite
Dental avulsion
Spider bite
Facial trauma