title: Evaluating the role of physical and radiographic examinations in assessing bullet tract termination for gunshot victims.
abstract: Knowledge of the path of a bullet and how it terminates is critical for expeditious assessment and optimal management of patients with gunshot wounds. To assess the accuracy of physical examination and X-rays in these patients, a prospective study was undertaken for all gunshot victims seen for a 1-year period on a single trauma service. The paramedics and trauma surgeons' physical examinations were evaluated for whether a bullet tract could be accurately categorized as 1) through and through, 2) graze, 3) palpable under dermis, or 4) retained (ie, not palpable). The impact of X-rays was assessed with regard to how it affected the trauma surgeons' categorization. A total of 78 patients were seen with a total of 120 bullet tracts. Seventy-seven per cent were injured by assault, and 64 per cent were shot with a 9-mm or .38-caliber handgun. Twenty of 60 (33%) bullet tracts on the torso terminated with a missile that was palpable under dermis, but only 2 of 10 neck (20%), 1 of 28 extremity (4%), and 1 of 22 head/face (5%) did so. Paramedics evaluated 15 torso bullet tracts that ended palpable under dermis, of which they detected 5 (33%). Upon initial examination, the trauma surgeon detected 11 of 20 torso bullet tracts that ended palpable under dermis (55%), and detected 14 of the 20 after X-rays were done (70%). Overall, obtaining X-rays changed the categorization for 15 of 111 bullet tracts (13%). We conclude that bullet tracts on the torso result in a subcutaneously palpable bullet one-third of the time, much more frequently than in other body regions. Paramedics only detect one-third of subcutaneously palpable missiles on the torso. X-rays change the categorization of bullet tracts infrequently. We recommend that a careful examination of the skin of the torso to detect palpable missiles be incorporated into the secondary survey of patients with wounds to that body region.
authors.affiliation: Northridge Hospital Medical Center, California, USA.
authors.forename: F
authors.initials: F
authors.lastname: Kennedy
authors.forename: J
authors.initials: J
authors.lastname: Sullivan
authors.forename: D
authors.initials: D
authors.lastname: Arellano
authors.forename: R
authors.initials: R
authors.lastname: Roulier
mesh_terms: D000488:Allied Health Personnel; D005260:Female; D006801:Humans; D008297:Male; D010173:Palpation; D011446:Prospective Studies; D011859:Radiography; D014194:Traumatology; D014948:Wounds, Gunshot / Q000175:diagnosis* / Q000000981:diagnostic imaging