Initial approaches to trauma resuscitation should be followed as noted earlier. Attention should be paid to the abdominal examination. If there is indication of peritonitis or of a gunshot with a transabdominal missile path, emergent surgical consultation should be obtained and preparations made for an exploratory laparotomy. Baseline hemogram, urinalysis, and rectal examination should be performed on all patients. If there is any concern of injury to the rectum because of blood being noted on rectal examination or because of the trajectory of the bullet, proctosigmoidoscopy should be performed. 10 Cystography should be performed on patients when there is blood on urinalysis or the proximity of the wound to the GI tract is a concern. Vascular injury to gluteal or internal iliac arteries has been reported from gluteal-penetrating wounds and may lead to exsanguinating external hemorrhage.11 An intrapelvic injury may also cause injury to the internal iliac vessels with hypovolemic shock; this will require early operative intervention. In all patients, the peripheral pulses in lower extremity should be examined looking for decreased pulses or pallor as evidence of a proximal injury. Neurologic examination of the lower extremities to document any injury to the sciatic or femoral nerve should also be performed on all patients. Buttock wounds rarely cause damage to the sciatic plexus or femoral plexus. Injury could include transsection, partial transsection, or stretch injury secondary to the trauma. The presence of any symptomatic signs requires appropriate consultation.
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