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Three Part Question

In [a young adults with an uncomplicated gunshot to soft tissue only] is [entry and exit wound care better than formal surgical debridement] in [preventing wound infection]?

Clinical Scenario

A 24 year old man is brought to the emergency department by his friends having been shot in the leg. Examination of the thigh reveals a through and through wound with no bone, nerve or major vessel involvement. You wonder whether simple entry and exit wound cleaning with or without antibiotics or surgical debridement is the best treatment.

Search Strategy

Medline 1966-03/00 using the OVID interface.
[[({exp firearms OR gun$.mp} AND {exp wounds and injuries OR wound$.mp}) OR exp wounds, gunshot OR gunshot$.mp] AND {exp exp irrigation OR lavage.mp OR exp debridement OR debridement.mp OR debride$.mp} AND {exp antibiotics OR antibiotic$.mp}] LIMIT to human AND english.

Search Outcome

77 papers found of which 75 irrelevant or of insufficient quality for inclusion. The two remaining papers are shown in the table.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Ritchie AJ and Harvey CF, 1990, UK	64 patients (116 wounds) with gunshot and blast injuries GA for exploration and pull-through (61) vs minimum debridement under LA and saline wash (55). Both groups had antibiotics for 3 days.	Controlled clinical trial	Infection rate	No significant difference	Not randomised
			Hospital stay	8.5 days vs 3.6 days.
Ordog GJ et al, 1993, USA	3390 of 3684 patients with minor gunshot wounds.	Cohort	Overall infection rate	1.8%
			Infection rate by antibiotic prescription	40% of patients were given antibiotics. 56% of infections were in patients with antibiotics, 44% in patients without.
			Complicating factors	Multiple injuries

Comment(s)

There are no randomised trials in this area. The largest study has identified complicationg factors but does not directly answer the question posed.

Clinical Bottom Line

Simple soft tissue gunshot wounds without complicating factors can be managed with minimum wound debridement and antibiotics.

References

1. Ritchie AJ and Harvey CF. Experience of low velocity gunshot innjuries: a more conservative approach in selected cases J Coll Surg Edin 1990;35(5):302-4.
2. Ordog GJ, Sheppard GF, Wasserberger JS et al. Infection in minor gunshot wounds J Trauma 1993;34(3):358-65.