Management of shotgun wounds: do we need classification systems?

Shotguns cause a wide variety of injuries, depending on the weapon-victim distance and the type of the gun and pellets. It has been suggested that the probability of significant internal injuries cannot be predicted using physical examination alone, and several wound classification systems have been proposed to facilitate clinical decision-making.

To evaluate the sensitivity of clinical examination and assess the role of a new classification system to detect significant injuries caused by shotguns.

The medical records of 56 consecutive patients admitted to a Level I trauma center with shotgun wounds from January 1994 to December 1996 were reviewed. Clinical examination was the main tool to select patients for emergency operation or nonoperative management. Wounds were classified by the number of body areas (abdomen, chest, head and neck, extremities) involved: grade I involved more than two areas, grade II two adjacent areas, and grade III one area.

Twelve patients had type I wounds, 25 had type II wounds, and 19 had type III wounds. Nineteen major operations for intrathoracic, intra-abdominal or peripheral vascular injuries were done on 16 patients, as well as 10 orthopedic, ophthalmological and urological procedures and three emergency room thoracotomies,. No differences were found in the incidence of operations, morbidity, mortality, or length of hospital stay among the three groups. Clinical examination was 100% sensitive and 93% specific in identifying the presence of significant organ injuries and need for emergency operation. Three patients had unnecessary abdominal explorations because they received anesthesia for other procedures and could not be reliably followed up clinically.

Clinical examination is the most reliable tool to identify patients who require emergency operation after shotgun wounds. Classification systems provide only crude information and do not predict reliably the presence of significant internal injuries.