Extremity gunshot wounds: Part one--Identification and treatment of patients at high risk of vascular injury.

Cost containment is important in this time of inner-city economic and health-care crisis. This paper examines patients who were treated for gunshot wounds (GSWs) of the extremities. During the study period 1978 through 1992, 16,316 patients (18,349 extremities) were treated for extremity GSWs. Nine patients with asymptomatic injuries in proximity to vascular structures who were treated before the use of duplex Doppler ultrasonography (DDU) were later found to have surgically treatable vascular injuries. These were identified and treated on an outpatient basis with no long-term morbidity or mortality. With the advent of DDU, asymptomatic vascular injuries were no longer missed. A conservative estimate of the cost savings from this study is more than $47,000,000.00. The use of DDU and the enclosed protocols for treating asymptomatic extremity wounds prevented 16,450 needless angiograms, with an additional savings of $32,900,000.00, for a total savings of more than $79,900,000.00. With a more liberal use of DDU and angiography to eliminate the rare missed vascular injuries (0.09%), and the use of protocols to analyze patients with asymptomatic injuries, many extremity GSW victims (79% in this study) can be safely treated as outpatients, eliminating the need for expensive in-hospital observation.