Hot Seat #164: Shot in the back

Posted on: January 26, 2021, by :

HPI: 14 year-old male arrives at the ED with a gunshot wound to the back. States he was hanging outside with friends when he heard shots and started to run. He heard multiple shots but felt one hit his mid back and fell down in pain. His friend immediately called 911. Denies any chest pain or difficulty breathing. Denies difficulty moving lower extremities, numbness, weakness, or tingling.

Initial VS: HR:116, BP:126/82, RR:14, SaO2: 100%  on 100% NRB mask

Primary survey: Airway intact, Breath sounds equal bilaterally, strong and equal peripheral pulses, GCS 15

Secondary survey:

Head/face/neck atraumatic, trachea midline

Chest stable with no ecchymosis or abrasion

Abdomen soft, no tenderness to palpation, pelvis stable

Back with penetrating wound at T8 just to the right of the spine, no active bleeding

Lumbar spine with 2nd penetrating wound at L2, no active bleeding

Bilateral LE no injury, 5/5 strength, sensation intact to light touch

Bilateral UE no injury, 5/5 strength, sensation intact to light touch

In the trauma bay:

2 IVs placed

Comprehensive trauma labs drawn

Chest and abdominal x-rays show no pneumo- or hemothorax, no bullet fragments seen

Patient’s Vitals are now: HR-127, BP: 132/78, RR-12, SAO2: 97%RA

He states that he is in 10/10 pain in his back

The patient is given fentanyl, cefazolin, and TdaP and is brought to an ED room for observation. On arrival to the room he still complains of severe pain and is given a dose of 6mg morphine. 30 minutes later the patient calls you to the room complaining of unchanged, severe back pain. Vitals are currently: HR 104 BP 130/84 RR 14 SP02 on 100% on RA and exam is unchanged.

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6 thoughts on “Hot Seat #164: Shot in the back

  1. The physical exam of no active bleeding from two penetrating wounds and X-rays with no bullet fragments with pain out of proportion just doesn’t add up right. I’d maybe check CRISP to see if this patient has been seen recently at other EDs. Could this be drug-seeking behavior?

  2. To Dewesh’s comment: I was assuming the penetrating wounds were fresh (despite no active bleeding). Malingering or drug seeking is low on my differential for fresh bullet wounds. With no bullet or fragments on CXR/AXR, is one of these wounds an entrance and one an exit? If so, needs more imaging (CT) Alternatively, they could just be graze wounds, but this should be apparent with a good PE.

  3. Agree with Jo that malingering is less likely on the differential for me, but could this be a stab or other type of wound? Also, with severe pain, could he have some kind of expanding hematoma causing pain? More imaging and input from surgery (and possibly neurosurgery if worried about vascular injury around the spine) might be helpful.

  4. The source of the pain needs to be actively pursued. I am interested in the exam once moved to a quieter room: is the pain localized, suggesting a bone injury (vertebra, rib) or is it diffuse over a region/side of the body, in which case I would think as Sarah says of expanding hematoma in a muscle or in a solid organ. Follow up on labs/UA to see if these point to a more specific injury. I would have a discussion with Trauma and Radiology about next imaging, which will likely be a CT chest/abdomen/pelvis with contrast.

  5. Without imaging confirming location of the round, you really have to assume that the pain is real and secondary to the trauma in my mind. You can and do get spinal trauma without neurological findings and depending on the round’s caliber (size) and velocity (was it a ricochet, etc) could easily get lodged against that spine and cause really, agonizing pain. Have great anecdote about this….

  6. I’d be concerned about a retroperitoneal hematoma with penetrating back wounds and progressively worsening back pain. Bullet might also be lodged right next to spine, causing bony pain, but I’d have expected that to be more constant vs worsening over time. If there was an US- trained person, I’d have wanted a FAST in the trauma bay to look for hemo- or pneumothorax and intra-abdominal blood. This wouldn’t catch a retroperitoneal bleed though- will need a CT. Also: where are the bullets?? Maybe obscured by the bones of the spine on a single view XR? Seems implausible that those locations could be an entry and exit wound from the same bullet if shot while running away.

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