23 Imaging Triage for Ballistic Trauma Stephen C. Gale and Vicente H. Gracias 479 Introduction The initial evaluation of victims of ballistic trauma is largely dependent on the physical examination and physiologic status of the patient. Patients are fully exposed and wounds are carefully examined in an attempt to deter- mine trajectory. Based on the suspected path of the missile, determinations can be made as to what structures are likely injured and what interventions may be needed. All who care for the injured patient agree that there is a limited role for radiologic assessment in hemodynamically unstable patients. However, in those patients without physiologic compromise, radiologic evaluation can serve as a very useful adjunct in the triage of patients toward more inva- sive studies, surgical intervention, or nonoperative management. Routine plain film radiographs remain an essential tool in the initial evaluation of all victims of penetrating trauma. Nevertheless, an increasing role has devel- oped for additional diagnostic modalities including surgeon-performed ultrasound, computed tomography (CT), and angiography in those who are stable and have a questionable need for operation or uncertain trajectory. With the expansion of these accurate and versatile imaging modalities, many traditional principles in the management of ballistic trauma patients are being redefined. Chest Films All gunshot victims, irrespective of the area injured, should routinely undergo portable anteroposterior (AP) radiography of the chest. This important and inexpensive screening tool quickly excludes many life- threatening conditions. When possible, every effort should be made to perform this study with the patient’s torso in the upright, seated, or reverse Trendelenberg position. This may allow earlier diagnosis of perforated RAU23 10/21/04 06:43 PM Page 479