A mouthful of trouble

The prehospital providers in this case performed a thorough and detailed assessment. They searched for and found a puncture wound in the posterior buccal region, and learned the patients was also hypoglycemic, with a history of diabetes, and insulin-dependent. It was not clear how the patient arrived at a hypoglycemic state, or if he had suffered a seizure. After the family arrived at the hospital and went to the patient's home, they determined the circumstances that caused this unusual presentation: The patient was the victim of a home-invasion robbery and had been shot in the mouth with a small-caliber weapon. The home invasion had taken place approximately 12 hours prior to the victim being found. The victim had been knocked unconscious by the force of the shot, although the bullet did not break any bones. He had not eaten prior to the shooting. Upon arrival at the ED, a small exit wound was noted behind the patient's left ear--hair and dried blood had obscured it from the prehospital providers. However, the providers did alert the ED physician to the buccal puncture wound, which enabled the physician to consider the possibility that the mouth wound was the result of a gunshot. Gunshot wounds are unpredictable in their damage patterns and effects on their victims. They might lead a patient to become hemodynamically unstable, but that was not the case here. Hemodynamic stability should not preclude the consideration of traumatic insult throughout your assessment. The initial presentation of this patient may have tempted EMS to pursue the suspicions stated by the neighbor at the scene (seizure), but a detailed assessment provided the information necessary to treat the man appropriately.