SAQ 199 – Trauma – shotgun wounds and forensic evidence

Question 6. shotgun wounds and forensic evidence.

a. Pre-arrival steps

• Activate the trauma team and notify anaesthesia, surgery, operating theatre, radiology, pathology, and cardiothoracic surgery.
• Prepare intubation, chest-drain, and ultrasound equipment.
• Prepare medications for haemodynamically unstable RSI.
• Activate the massive transfusion protocol.

b. ICC-only management

• No underlying bronchial injury.
• Initial thoracic blood loss below 1,000 mL.
• Ongoing loss below 250 mL/hour for four hours.
• No missile in the heart, IVC, or pulmonary artery.

c. Blurred missile fragment

• The fragment is moving and is likely within the heart or great vessels.

d. CT tractography

• May exclude peritoneal penetration in a tangential abdominal wound by injecting water-soluble contrast into the tract before CT.

e. Laparotomy

• All abdominal gunshot wounds should proceed to laparotomy unless the missile path is overtly tangential and extraperitoneal.

f. High-velocity chest injury

• Shattering of the heart causing immediate death.

g. Forensic evidence

• Preserve evidence and maintain a documented chain of custody.
• Store evidence securely until handover to a designated police officer.
• Collection should be by trained personnel without compromising emergency care.
• Use gloves and avoid contamination or destruction.
• Place clothing and articles in paper bags.
• Cut around, not through, missile holes.
• Preserve missile fragments.
• Label specimens clearly and accurately.
• Document the patient's own words without embellishment and use diagrams or photographs where appropriate.