A major concern with anterior abdominal gunshot wounds is to determine whether the missile traversed the peritoneal cavity. All patients with transabdominal gunshot wounds require exploration because virtually all of them will have intraabdominal pathology requiring surgery. Most often this can be determined by estimating trajectory. While it can be difficult to determine whether a hole is an exit wound or an entrance wound, a hole both in the anterior and posterior abdomen clearly defines a transabdominal trajectory. In the event of a single entrance, a plain film of the chest, pelvis, and/or abdomen often can determine trajectory. A lateral film may be necessary to help determine the trajectory precisely. A missile in a location that defines a transabdominal pathway mandates exploration.
Occasionally, in the case of tangential injuries or multiple gunshot wounds, it may be impossible to clearly estimate trajectory. Several options exist. It often may be safest to simply explore the patient. While the rate of nontherapeutic laparotomy may be relatively high, surgical exploration at least ensures that a potentially life-threatening injury will not be missed. The second option is to very carefully observe the patient with frequent physical examinations and laboratory values. The last option is to perform a peritoneal lavage. There are virtually no data that determine the correct threshold for red or white blood cell positivity in patients with gunshot wounds. The only purpose is to determine whether the missile traversed the abdominal cavity. Thus we generally set the threshold very low and explore patients if there is even a pink tinge to the effluent or the red blood cell count is 5000/cc.
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