Gunshot Wounds (Arms and Legs)

Evaluate 5 important structures when evaluating gunshot wounds in an extremity.

Blood Vessel Injuries

  • 3 Categories
    • Hard-Signers
      • Mnemonic: HARD Bruit
        • Hypotension
        • Arterial/pulsatile bleeding
        • Rapidly expanding hematoma
        • Deficits (pulse)
        • Audible BRUIT/thrill
      • These patients likely need OR
    • Soft-Signers
      • Significant vascular oozing/bleeding
      • Large hematoma
        • These patients need to be screened with ABI (ankle brachial index)
          • ABI <0.9 or asymmetry between extremities is concerning for vascular injury
        • If abnormal, obtain a CTA
    • No-Signers
      • No additional management for vascular injury required

Nerve Injuries

  • Relatively rare
  • Document neuro exam in the extremity
  • Consult if abnormal

Bone Injuries

  • Relatively common
  • Diagnosed by x-ray
  • Consult orthopedics for fracture

Soft Tissue Injury

  • Be sure to count/document number of holes
  • Typically do not need laceration repair unless cosmetic area
  • Don’t miss compartment syndrome
    • Mnemonic: “P’s”
      • Pain out of Proportion
      • Pain with Passive range of motion
      • Paresthesias
      • Pallor
      • Paralysis
      • Poikilothermia

The Bullet: What To Do With It?

  • The bullet is almost never removed, unless…
    • Very superficial/cosmetic and easy to remove
    • In a joint

Additional Reading


  1. peter s

    The neck trauma podcast listed neurologic deficit as a hard sign. Would you send a patient to the OR for neuro deficit with GSW to the neck? what about GSW to the extremity?

    • Zack

      If a patient has hard signs after neck trauma, they will almost certainly need the OR. For extremity trauma, it depends on the deficit and what could potentially be repaired.

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