Gunshots, Stabbings and Other
Nefarious Acts…
April 2010 CE
Condell Medical Center EMS System
Prepared by: Lt. William Hoover, Medical Officer
Wauconda Fire District
Reviewed/revised by: Sharon Hopkins, RN, BSN, EMT-P
Revised 4.12.10
1
Objectives
• Upon successful completion of this module, the EMS
provider will be able:
• Identify epidemiologic facts for firearm related
injuries
• Identify relationship between kinetic energy and
prediction of injury
• Identify how energy is transmitted from a
penetrating object to body tissue
• Identify characteristics of handguns, shotguns and
rifles
• Identify organ injuries associated with gunshot
injuries
2
Objectives cont’d
• Identify management goals for a patient with gunshot
wounds
• Identify items that could cause stab/penetration
trauma
• Identify potential internal organ injuries dependant on
item causing stab/penetration injury
• Identify management goals for a stab/penetrating
trauma patient
• Identify adult fluid challenge issues
3
Objectives cont’d
•
•
•
•
Identify adult fluid challenge dosages
Identify pediatric fluid challenge issues
Identify pediatric fluid challenge dosages
Identify procedures for implementation of
intraosseous infusion
• Demonstrate implementation of intraosseous
infusion
• Demonstrate insertion of a saline lock
• Demonstrate calculation of pediatric fluid challenge
dosage
4
Gunshots…
5
Gunshot Victims
6
Firearm Related Injuries
• Gunshot wounds are either penetrating or
perforating wounds
• Technical terms:
– Penetrating gunshots are when the bullet
enters, but does not come out of the body.
– Perforating gunshots are when the bullet
enters and exits the body
7
Perforating Gunshots
8
Penetrating gunshot
9
Entrance wound
• Surrounded by a
reddish-brown area
of abraded skin,
known as the
abrasion ring
• Small amounts of
blood
10
Mechanism of Energy Exchange
• As bullet passes through tissue, it decelerates,
dissipating and transferring kinetic energy to
tissues
– Cause of the injury
• Velocity more important than mass in
determining how much damage is done
– Small bullet at high speed will do more
damage than large bullet at slow speed
11
Mechanism of Energy Exchange
• High velocity
– High powered rifles; hunting rifles
– Sniper rifles
• Medium velocity
– Handguns, shotguns
– Compound bows and arrows (higher energy released)
• Low velocity
– Knives, arrows
– Falling through plate glass window, stepping on
things, bits flung by lawnmower
12
Medium & High Velocity
• These items are usually propelled by
gunpowder or other explosive
• Faster the object, the deeper the injury
• Causes damage to the tissue it impacts
• Creates a “pressure wave” which causes
damage frequently greater than the tissue
directly impacted
• If bone is struck, bone shatters and multiple
bone fragments are dispersed
13
Low velocity
• Usually a result of items such as knives that
are propelled by a person’s own power
– Also includes objects inadvertently stepped on
– Includes many objects a patient may be impaled
on
• Damage usually limited to the area directly in
contact with the object
14
Types of Firearms
• Pistols
– Revolver
– Semi-Automatic
• Shotguns
– Pump
– Semi-Automatic
• Rifles
– Bolt
– Lever action
15
Pistols – Medium Velocity
16
Shotguns – Medium Velocity
17
Rifles – High Velocity
18
Projectiles – High Velocity
• Rifle bullets are
designed to have
much greater
velocity than
shotgun bullets
• Different size of
casing provides
more or less
gunpowder
19
7 mm rifle shell – High Velocity
• Bonded design for deep
penetration and 90%+
weight retention
• Streamlined design
delivers ultra-flat
trajectories
• Devastating terminal
performance across a
wide velocity range
• Unequaled accuracy and
terminal performance for
long-range shots
20
Projectiles – Medium Velocity
• Shotgun ammunition
can be a variety of kinds
• Slugs are one large
bullet in the shell
• Some shells contain
numerous pellets of
various sizes
• This can influence
patient’s injuries
21
Shotgun Shell – Medium Velocity
12 Gauge Shotgun Slug
12 Gauge Shotgun with #6 shot
22
.38 caliber pistol ammunition
• Controlled expansion to
1.5x its original
diameter over a wide
range of velocities
• Heavier jacket stands up
to the high pressures
and velocities of the
highest performance
handgun cartridges
23
Compound Bows and Arrows –
Medium Velocity
24
Arrowhead Types – Medium Velocity
Target tips
Broadhead
25
Arrow injuries
26
Another ouch….
• How would
you stabilize
and dress
these
wounds?
27
Principles of Wound Care
• What are principles of wound care for the two
previous wounds?
– Scene safety
– Control bleeding
• Usually little to no bleeding while object still
impaled
– Prevent further damage
• Immobilize the object in place
–Gauze, tape, whatever it takes
– Reduce infection
• Prevent further contamination
28
Different Types of Knives
• Knives come in a wide
variety of shapes and
sizes
• The type of knife can
influence the injuries a
patient may have
• Hilt/handle of knife
does not necessarily tell
how long the knife is
29
Anticipation of Injury
• Trajectory may be straight or not
• Knowing anatomy helps anticipate organ
injury
• Anticipating organ injury helps in knowing
what signs and symptoms to watch for
• Anticipation of injury = proactive care
– Head wound = monitoring level of consciousness
– Chest wound = assessing lung sounds
– Abdominal wound = assessing internal blood loss
30
Stabbings
• 15 year old stabbed in
the head at a London
bus stop
• Cannot determine from
the outer wound what
the damage is internally
• Assume the worse
• Stabilization of impaled
objects extremely
crucial
31
Police Officer Stabbing
What injuries do you suspect?
32
Organ Injury
Patient was shot
with a MAC-10
machine gun and
sustained a
liver injury
Lap sponge under fold of skin
Liver surface with injury noted to organ
33
Scene Safety
• Attacks at both
Columbine and Virginia
Tech had well armed
offenders
• EMS and Police must
work through a unified
command structure to
provide maximum
safety
34
Scene Safety
• Not exclusive to schools
– Fort Hood, TX Shooting (2009)
– Colorado Church Shootings (2007)
– Queens, NY Wendy’s Shooting (2000)
– Atlanta Day Trader Shooting (1999)
– San Ysidro McDonald’s Shooting (1984)
35
Management Goals
•
•
•
•
•
•
Short on scene time! Under 10 minutes!
Immediate life threatening issues addressed
Rapid move to ambulance
Good BLS skills
ALS treatment while enroute
Transport to Level 1 Hospital, if under 25
minutes
• Transport to closest hospital if Level I >25
minutes away
• Consider helicopter in unique situations
36
Management Goals
• Critical patients need rapid transport per SOP
• Difficult to assess internal damage in the field
• Stop any visible bleeding that could cause
hemorrhage  hypovolemia
• Address airway issues
– Tension Pneumothorax chest decompression
– Suction to keep airway open
– Intubate to secure the airway
• Surgery is the answer to critical gunshots
37
Management Goals
Focus on the basics
If there is a hole – plug it
If there is bleeding – stop it
If they can’t breathe – ventilate
38
Scene Management Review
• Columbine shooting showed areas that police
needed to address
– Previously philosophy for police was to secure
area and wait in perimeter for SWAT to arrive
– But, this allowed shooter to continue
unobstructed
– Police now form team early and enter the building
to engage shooter providing containment
– Prevents shooter from continuing rampage
39
Thoughts - Scene Management
• EMS/Fire has not been as proactive
• Staging vs. Entry
– Some agencies are sending first patrol officers in
to engage/contain offender
– Next group in is two medics with two police
escorts
– Treat patient and move on until running out of
supplies, then retreat to remove victims
– Provide aggressive care and move fast
– Departmental policies need to be reviewed
• Preferable to review with police input
40
Scene Management
• Use MABAS to get more help early
• Activate the Multiple Patient Incident Plan
• Multiple staging areas
– Explosives could be set for responders
– Easier deployment to variety of areas
– Downside is less scene control
41
Categorizing The Patient
• Perform scene size-up
• Perform initial assessment
– Purpose – determine presence of life threats
•
•
•
•
•
Open airway/perform spinal precautions
Evaluate breathing
Evaluate circulation
Obtain AVPU and GCS scores
Obtain general impression
– Identify priority of transport
42
Region X
Field Triage Criteria For Assessing
Trauma Patients
43
Patient Transport Decision
• Critical and Category I trauma patients
– Transported to highest level Trauma Center
within 25 minutes
• Aeromedical transport remains an option
especially in lengthy extrication and
distance from the hospital
44
Categorizing The Critical Patient
• Systolic B/P < 90 x2
– Pediatric patient B/P < 80 x2
• Blood pressure values taken at least twice and
5 minutes apart
• These patients transported to highest level
Trauma Center within 25 minutes
45
Categorizing The Category I Trauma
Patient
• Unstable vital signs
– GCS < 10 or deteriorating mental status
• Best eye opening – 4 points max
• Best verbal response – 5 points max
• Best motor response – 6 points max
– Respiratory rate <10 or >29
– Revised trauma score < 11
• Range 0-12
– 3 components added together
» Converted GCS (3-15 score converted to 0-4 points)
» 0 - 4 points for respiratory rate
» 0 - 4 points for systolic blood pressure
46
Categorizing The Category I Trauma
Patient
• Anatomy of injury
– Penetrating injuries to head, neck, torso, or groin
– Combination trauma with burns > 20%
– 2 or more proximal long bone fractures
– Unstable pelvis
– Flail chest
– Limb paralysis &/or sensory deficits above wrist or
ankle
– Open and depressed skull fractures
– Amputation proximal to wrist or ankle
47
Patient Transport Decision
• Category II trauma patients
– Transported to closest Trauma Center
• These are stable patients with significant mechanism of injury
• You know they are stable because of frequent reassessment
• There is the potential for these patients to become unstable
– Recognize that pediatric patients often pull you into false
sense of security (but so can adults)
• Peds patients maintain homeostasis as long as possible
and when compensation fails, they deteriorate fast
48
Categorizing The Category II Trauma
Patient
• Mechanism of injury
– Ejection from automobile
– Death in same passenger compartment
– Motorcycle crash >20 mph or with separation of
rider from bike
– Rollover – unrestrained
– Falls > 20 feet
• Peds falls > 3x body length
49
Category II Trauma Patient cont’d
• Mechanism of injury cont’d
– Pedestrian thrown or run over
– Auto vs pedestrian / bicyclist with > 5 mph impact
– Extrication > 20 minutes
– High speed MVC
• Speed > 40 mph
• Intrusion > 12 inches
• Major deformity > 20 inches
50
Category II Trauma Patient
• Co-morbid factors
– Age < 5 without car/booster seat
– Bleeding disorders or on anticoagulants
– Pregnancy > 24 weeks
51
Category III Trauma Patient
• All other patients presenting with traumatic injuries
– Fractures
– Sprains/strains
– Burns
– Falls
– Pain
• Provide routine trauma care
– Honor patients request for hospital choice as
much as possible
52
Communication
• Call early; update as needed
– Hospital staff and resources may need to be
mobilized
• The more critical the patient, most likely the
shorter the report
– Give important details
– Paint the picture head to toe
– Just as important is to give tasks not completed
• Intubation versus bagging
• IV access obtained or not
53
Abbreviated Radio Report
 Provide department name, vehicle number and
receiving hospital
 State, “this is an abbreviated report”
 Provide nature of situation and SOP being followed
 Age and sex of patient
 Chief complaint and brief history
 Airway and vascular status
 Current vital signs, GCS
 Major interventions completed or being attempted
 ETA
54
Fluid
Challenges
55
Adult Fluid Challenge
• Adult fluid replacement is in 200 ml
increments (replacement formula 20 ml/kg)
• Storage issues
– IV bags are usually in ambulance, in bays
– Fluid eventually are at ambient temperatures
– 70° fluid into 98.60 body will cause core body
temperature to decrease
– Hypothermia results
– Cold patients become acidotic patients
56
Adult Fluid Challenge
• 200 ml increments
– Formula is 20 ml/kg
– Example
• 200 # patient = 100 kg
–100 kg x 20 ml/kg = 2000ml fluid challenge
– Reassess your patient as you are passing the
200 ml mark
– Monitor breath sounds for fluid overload
57
Adult Fluid Challenges
• Vascular issues
– Vessel damage results in extensive blood loss
– EMS infuses Normal Saline
– NS does not carry oxygen; NS solves volume issue
only
– Volume can be filled, but patient still in distress
due to lack of oxygen carrying capacity (ie: blood)
– Goal should not be to get a 120/80 blood
pressure, rather to stabilize
58
Adult Fluid Challenges
• If your patient’s blood is becoming pink, they
need more blood in the system!
• EMS typically does not carry blood in the field
• Important to accelerate transport to a facility
that can add the blood and do the surgery to
repair the underlying problem!!!
• Good BLS skills are more important than ALS
skills for these types of patients!
59
Pediatric Fluid Challenges
• Pediatric shock protocol
– EMS carries Normal Saline
– Formula 20 ml per kg for fluid bolus
– Can be administered up to three times total or up
to 60 ml per kg total
• Smaller container (patient size) means less
fluid means less oxygen carrying capacity
• Example:
• 30# patient = 14 kg (30  2.2)
– 14 x 20ml/kg = 280 ml fluid challenge
60
Fluid Challenge Calculations
• 6 year old patient weighs 66 pounds
– 66 pounds = 30 kg
– Fluid challenge of 30 kg x 20 ml = 600 ml each time
• 15 year old patient weighs 175 pounds
– 175 pounds = 80 kg
– Fluid challenge of 80 x 20ml = 1600 ml fluid
• 25 year old patient weighs 120 pounds
– Adult gets fluid challenge in 200 ml increments
• 75 year old patient weighs 180 pounds
– Adult gets cautious fluid challenge in 200 ml increments
61
Fluid Challenges
• Precautions
– All patients need to be monitored for potential
CHF
– Even a previously healthy patient can be thrown
into CHF
• Too much fluid too fast
62
Case Study #1
•
•
•
•
•
•
•
Dispatched for double shooting @ 0942
Ambulance enroute @ 0942
Ambulance staged @ 0947
Flight for Life notified @ 0952
Scene secured by police @ 1000
FFL in the air @ 1000
Patient contact @1002
63
Case Study #1
•
•
•
•
Ambulance enroute to landing zone @ 10:13
FFL on ground @ 10:15
FFL to Level I @ 10:23
.38 caliber revolver pistol used in the shooting
64
Case Study #1
• Patient #1
– 38 year-old female with multiple gun shot wounds
– Found in the basement of the house
GSW to right hand (entry and exit)
GSW to right side of neck (entry) and lower right
ribcage (exit)
GSW to right forearm (entry and exit)
GSW to right humerus (entry and exit)
GSW to left hand (entry and exit)
65
Case Study #1
• Patient #1
– Approximately 2 liters of blood loss
– Responding to verbal stimuli
– Pupils: PERL
– Lungs: left (clear), right (rhonchi), normal effort
– Skin: Pale, dry, cool with delayed capillary refill
– Past medical history, meds & allergies unknown
– Unable to obtain B/P, femoral pulse @ 110
66
Case Study #1
• Respirations 22 with SPO2 of 94% on room air
– SPO2 increased to 99% after oxygen @ 15 L via
NRB
• ECG: Sinus tachycardia with rate of 110
• Patient disoriented
• GCS = 9; RTS = 10
67
Case Study #1
• Treatment plan:
– Scene safety
– Additional units requested, including FFL
– ABC’s performed
– Immobilization by c-collar, backboard & head
immobilizers
– Patient moved to ambulance
– Patient exposed with multiple gunshot wounds
discovered
68
Case Study #1
• Bleeding controlled to entry & exit wounds
with trauma dressings
• Oxygen administered at 15 L via NRB mask
• IV of Normal Saline administered with 18 G in
left extremity, wide open rate
• Crew monitored lung sounds and femoral
pulse throughout
• Patient transferred to FFL crew
• CMC (as Medical Control) notified
69
Case Study #1
• Patient #2
– DOA from self inflicted gun shot wound
– Was going through a divorce and called patient #1
to come pick up the kids
– When Patient #1 arrived, Patient #2 asked her to
step into the basement where he shot her
multiple times and then turned gun on self
– Children’s grandparents had also been called to
pick up the kids
70
Case Study #1
• Is this a Category I or II trauma patient and
why?
– Systolic B/P below 90
– GCS less than 10
– RTS less than 11
– Penetrating injuries to head, neck, torso or groin
71
EZ IO
• Have you used one on a
patient?
• High risk, low volume
procedure
– To retain competency need
review and practice
72
EZ IO
• Indications
– Must meet all indications
• Shock, arrest, or impending
arrest
• Unconscious/unresponsive
to verbal stimuli
• 2 unsuccessful IV attempts
or 90 seconds duration
73
EZ IO
• Contraindications
– Fracture of the tibia or femur
– Infection at insertion site
– Previous orthopedic procedure (knee
replacement, previous IO insertion within 480)
– Pre-existing medical condition (tumor near site,
peripheral vascular disease)
– Inability to locate landmarks (significant edema)
– Excessive tissue at insertion site (morbid obesity)
• Hold leg up off bed to allow excess tissue to fall
dependently
74
EZ IO Equipment
• Lithium drill
– Battery powered for 1000 insertions
• Needle
– Blue needle – 25 mm (1) 15 G for patients over 88 pounds
(40kg)
– Pink needle – 15 mm (5/8) 15G for patients between 7 and
88 pounds (3kg – 40kg)
•
•
•
•
•
•
EZ connect tubing
Syringe
Saline to prime EZ connect tubing
Primed IV bag
Pressure bag/B/P cuff
Site prep material (ie: alcohol pad)
75
Equipment Case
EZ connect tubing
10 ml syringe
with saline
Needle sizes used in Region X
76
EZ IO Procedure
• Prime EZ connect tubing with saline; leave syringe
attached (for flushing)
• Locate and cleanse site
– Proximal medial tibia
•
•
•
•
•
•
•
Prepare driver and needle set; remove safety cap
Insert needle at 900 angle
Remove stylet
Attach primed EZ connect tubing
Aspirate then flush line with remaining saline
Remove syringe only and connect primed IV set
Confirm needle placement
77
Identifying
Site
• Proximal medial tibia
– 2 finger breadths below patella (to tibial
tuberosity) and 1 finger breadth medially from
tibial tuberosity
– May or may not be able to identify the tibial
tuberosity at 2 finger breadths below patella
– As patient is lying supine, legs tend to roll slightly
outward
• This presents the flat surface of the tibia
78
Confirming EZ IO Placement
• Sudden lack of resistance
felt
• Needle stands up by self
• Bone marrow may be
noted on aspiration
• No resistance to flushing
• IV runs with pressure
applied to IV bag
• No infiltration noted
79
80
Documentation OF EZ IO Insertion
• Document usual IV insertion information
– Time of insertion
– Size IV bag used
– Site, needle length, needle gauge
– Amount of fluid infused in the field
• Place fluorescent yellow arm band on patient’s wrist
to indicate insertion (or attempt) of IO
– Recommended to place on same side as insertion
site
– Arm band used for successful and unsuccessful
insertions
81
EZ IO PI
• Complete PI
form for every
use of the EZ IO
needle
• Submit PI form
to the EMS
coordinator
with the EMS
run report
82
Saline Lock/Extension Tubing
• Indication
– To establish an extension line between the IV catheter and
the IV tubing
• Allows hospital staff to change IV tubing with less disturbance to
the inserted IV catheter
– To have access to circulation without the need for fluids
• Equipment
–
–
–
–
IV start pak
IV catheter
Macrobore extension set (7.25 inches)
10 ml saline in syringe for priming tubing and flushing
83
Region X SOP - Saline Lock
• Routine medical care SOP states:
– Establish 0.9 normal saline (NS) per IV/IO and
adjust flow as indicated by the patient’s condition
and age
– May use a saline lock cap on
IV catheter hub for stable
patients (not needing fluid
resuscitation)
84
Terminology Saline Lock – Extension Tubing
• Note:
– Saline lock is an older term
• Tends to mean a small cap device inserted into the proximal end of
an IV catheter; no extra tubing
– Equipment to be used
• Macrobore extension tubing with clave port
– 5-7 inches of tubing with a male end to connect to the
proximal IV catheter
– Clave port on proximal end for connecting IV tubing or
attaching a syringe
• Nowadays, if you say “saline lock” the macrobore and
microbore tubing is the device the general hospital
person would think you are discussing
85
“Saline Lock” Procedure
• Establish an IV following sterile technique
• Remove stylet
• Insert distal tip of primed extension tubing/ saline
lock into IV catheter
– If administering fluids, IV tubing should be already
attached to the extension tubing/saline lock
• Adjust flow rate
• If IV line is precautionary, flush extension
tubing/saline lock with 10 ml sterile normal saline
– Remove syringe
– Do not need IV tubing or IV bag
86
Extension Tubing/Saline Lock
• Connecting to IV catheter
– Keep IV site as distal as possible
• AC should not be your first choice
• We are requesting to start getting into habit of
adding this extension tubing to all IV starts
87
IV Equipment for Saline Lock
• If patient needs fluid, attach primed IV tubing with bag to
proximal end of extension tubing/saline lock
–
–
–
–
–
Wipe off blue clave port with alcohol prep pad
Push in and twist primed IV tubing to connect
Adjust flow rate as indicated
Document time, type, and size IV solution hung
Distal tip of clave inserted into IV catheter
88
Extension tubing/Saline Lock In Place
• Extension tubing/saline lock properly secured
– Insertion site not taped over
– Clear view of insertion site through op-site/tegaderm
dressing
– Access to port available
– Can easily attach primed
IV tubing if need to begin
fluid therapy
89
Improperly Secured IV Site
• Insertion site taped over
• Gauze bandaging under tape
– Increased risk of infection
IV site properly covered with see
through dressing
90
Extravasation of Medication
• To use the extension tubing/saline lock for
infusion, must verify that the line is patent
– Aspirate for blood return
– Stop infusion if patient complains of pain/burning
Extravasation of IVP
medication resulting in
amputation of several fingers
91
Case Study #2
•
•
•
•
•
25 year old male shot in the chest
Police are on the scene
Patient sitting on ground, leaning against car
Several small casings on ground near victim
Patient bleeding from small chest wound left
anterior chest
• Patient is anxious, pale, diaphoretic with
elevated respiratory rate
92
Case Study #2
• Patient alert and oriented x3
• Complains of mild chest pain aggravated with
deep breathing
• VS: 122/86, 90 – 20
• Hole noted in the left anterior chest about the
3rd intercostal space
– No air seems to be moving through the hole
93
Case Study #2
• What questions do you have?
– Has the patient been searched?
• The patient had not been searched
• A small pocket knife was retrieved by police
• Is there anything else to be done for assessment?
– Check for multiple bullet wounds
– Evaluate all sides of the patient
• A large wound was noted on the patient’s left back
94
Case Study #2
• Interventions required
– Immediately seal the open wounds
• Dressing secured on 3 sides
– Provide high flow oxygen via non-rebreather
– Establish IV access
– Contact Medical Control
• What Category trauma is this patient?
–Category I – penetration of torso
95
Case Study #2 - Documentation
• “Upon arrival found patient handcuffed.
States, “they shot me” a few minutes ago.
Bleeding is controlled. Patient states only mild
pain especially with a deep breath. IV, O2,
monitor applied. Level I trauma center
notified. Police informed of hospital
destination.”
• What’s wrong with this documentation?
96
Case Study #2
• No description of injuries noted
– Size, location, presence/absence of bleeding
– Lack of documentation of gun used when
information is known
• No documentation of 3 sided dressing applied
• No documentation of response to treatment
• Interventions (ie: IV, O2, monitor) do not need
to be reduplicated in the comments
• No documentation of police in ambulance due
to patient being handcuffed
97
Case Study #3
• 911 call to scene for a domestic incident
• Upon arrival, summoned to the back yard for a 23
year old female patient lying on the ground
conscious and awake
• Patient states she was running out of the house and
tripped down the stairs
• Tree branch noted impaled through right flank at
level of umbilicus
• VS: 124/100; 120; 22; SpO2 98%; warm & dry
• No active bleeding
98
Case Study #3
• What actions are
necessary for EMS to
take for:
– Scene safety?
– Initial assessment?
– Interventions?
– Reassessment?
99
Case Study #3
• Scene safety
– Is the scene secured?
– Where is the husband; who is with the husband?
• Initial assessment
– Airway – open
– Breathing – without distress although patient is upset
– Circulation – warm & dry; capillary refill 1 ½ seconds;
pulse steady and palpable at the radial site
– AVPU – awake, cooperative, anxious
100
Case Study #3
• Categorization?
– Category I – penetrating object to torso
• Interventions
– Secure impaled object, prevent further movement
• Manual control initially
• Gauze padding around entrance site
• Assess for exit wound
101
Case Study #3
• Reassessment
– What internal injury is anticipated?
• Abdominal
– Solid organ – bleeding
– Hollow organ – spilling contents causing contamination
– Punctured vessels  hemorrhage
• Chest
–
–
–
–
Punctured diaphragm
Punctured lung
Punctured heart
Punctured vessels
102
Case Study #3
• Patient taken to OR
• Stabilization maintained to prevent movement
of impaled object
• Tree branch removed under direct
visualization
• Abdominal cavity cleaned and flushed
• Patient did well and was discharged 5 days
post-op
103
Case Study #4
• Responded to a call at a tavern for a person shot
• Upon arrival, the patient lying on their right
side, blood noted under their head
• Patient is breathing, radial pulse is palpable
• They do not open their eyes; the patient moans
when touched; the patient withdraws
• The bullet is visible in the wound
• What is first things first?
– SAFETY, SAFETY, SAFETY
104
Case Study #4
• Patient was in a local bar
• Was reported to be inebriated
• Was shot with a .25 ACP (relatively weak
round; assailant is gone)
• Patient slumped to ground from bar stool
• Describe your care
• Score the GCS
• What report do you provide to the ED?
105
Case Study #4
• Need to log roll patient
protecting C-spine
• Maintain clear airway
• GCS
–
–
–
–
Eye opening – 1
Verbal response – 2
Motor response – 4
Total GCS - 7
106
Case Study #4
• Cannot tell internal
damage by external
appearances only
• Patient had small bone
fragments that were
pushed into the brain
• Patient required
neurosurgery
evaluation
107
Case Study #4
• Report
– Description of wound(s) noted including body
region
– Include type of weapon used if information is
available
– Include distance from weapon if available
• Closer the range, the more energy that is
behind the bullet/shot the greater the internal
damage
– Note basic care provided (IV, O2, monitor)
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Case Study #5
• A patient presents as a walk-in to your
department
• Approximately 2 hours ago, he was involved in
a domestic disturbance
• Patient states his girlfriend hit him in the
upper chest and he continues to have some
pain and is now worried regarding the injury
• Awake and alert, vital signs stable
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Case Study #5
• You can’t assess what you can’t see – remove clothing
• What injuries do you anticipate?
– Heart, lung, vessels
– Trachea
– Esophagus
Visible wound
Object viewed on x-ray
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Case Study #5 – Operative View
• Impaled object after removal
• Was near pulmonary artery but no damage
• Knife missed all vital structures
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Case Closure
• What saves lives when impaled/penetrating
objects are involved?
Age and condition of patient
• Younger patients and those in good health can
tolerate the insult better
Rapid identification and transport form the
field
Proper stabilization of the object to prevent
further damage by movement
Rapid OR for direct visualization and repair
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Thank you!
HAVE A SAFE SHIFT!
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Bibliography
• Hoover, C. Fluid Resuscitation Controversies. EMS
Magazine. March 2010.
• Proehl, J. Emergency Nursing Procedures, 4th Edition.
Saunders. 2009.
• Region X SOP March 2007; amended January 1, 2008.
• Smith, M. Lecture. “Working Together” EMS Conference
2010.
• Wauconda Fire Department call records
• Olliver.family.gen.nz/launchpad/Head_wound.png
• www.cabelas.com<http://www.cabelas.com>
• www.jems.com<http://www.jems.com>
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Bibliography cont’d
•
•
•
•
www.remington.com<http://www.remington.com>
www.vidacare.com
www.Wikipedia.org<http://www.Wikipedia.org>
www.winchester.com<http://www.winchester. com>
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