Penetrating Trauma ECRN Mod II 2010 CE Condell Medical Center EMS System IDPH Site code #107200E-1210

1. Penetrating TraumaECRN Mod II 2010 CECondell Medical Center EMS SystemIDPHSite code #107200E-1210 Prepared by: Lt. William Hoover, Medical Officer Wauconda Fire District Reviewed/revised by: Sharon Hopkins, RN, BSN, EMT-P

2. Objectives • Upon successful completion of this module, the ECRN 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

3. 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

4. Objectives cont’d • Identify adult fluid challenge dosages • Identify pediatric fluid challenge issues • Identify pediatric fluid challenge dosages • Identify indications for implementation of intraosseous infusion • Calculate pediatric fluid challenge dosages

5. Gunshots…

6. Gunshot Victims

7. 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

8. Perforating Gunshots

9. Penetrating gunshot

10. Entrance wound • Surrounded by a reddish-brown area of abraded skin, known as the abrasion ring • Small amounts of blood

11. Mechanism of Energy Exchange • As bullet passes through tissue, it decelerates, dissipating and transferring kinetic energy to tissues • Cause of the injury is the kinetic energy • 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

12. 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

13. 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

14. 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

15. Types of Firearms • Pistols • Revolver • Semi-Automatic • Shotguns • Pump • Semi-Automatic • Rifles • Bolt • Lever action

16. Pistols – Medium Velocity

17. Shotguns – Medium Velocity

18. Rifles – High Velocity

19. Projectiles – High Velocity • Rifle bullets are designed to have much greater velocity than shotgun bullets • Different size of casing provides more or less gunpowder

20. 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

21. 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

22. Shotgun Shell – Medium Velocity 12 Gauge Shotgun Slug 12 Gauge Shotgun with #6 shot

23. .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

24. Compound Bows and Arrows – Medium Velocity

25. Arrowhead Types – Medium Velocity Target tips Broadhead

26. Arrow injuries

27. Another ouch…. • How would you initially stabilize these wounds?

28. Principles of Wound Care • What are principles of wound care for the two previous wounds? • Scene safety – even in the ED • 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

29. 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

30. Anticipation of Injury • Trajectory may or may not be straight • 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

31. 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

32. Police Officer StabbingWhat injuries do you suspect?

33. Organ Injury Lap sponge under fold of skin Patient was shot with a MAC-10 machine gun and sustained a liver injury Liver surface with injury noted to organ

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. Field 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

36. Field 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

37. Region XField Triage Criteria For Assessing Trauma Patients

38. Field Management Goals • Short on scene time! Under 10 minutes! • Immediate life threatening issues addressed • Good BLS skills • ALS treatment while enroute to the hospital • Report called as early as possible • Transport to Level 1 Hospital, if under 25 minutes • Transport to closest hospital if Level I >25 minutes away • Helicopter considered in unique situations

39. Patient Transport Decision From the Field • 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

40. Field Categorization of 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

41. Field Categorization of 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

42. Field Categorization of 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

43. Patient Transport Decision From the Field • 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

44. Field Categorization of 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

45. 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

46. Category II Trauma Patient • Co-morbid factors • Age < 5 without car/booster seat • Bleeding disorders or on anticoagulants • Pregnancy > 24 weeks

47. 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

48. Field to Hospital Communication • EMS to call early; update as needed • Gives time for hospital staff and resources to be mobilized • The more critical the patient, most likely the shorter the report • Important details to be given • Head to toe picture needs to be painted • Just as important to give tasks not completed • Intubation versus bagging • IV access obtained or not

49. Abbreviated Radio Report • Department name, vehicle number and receiving hospital • EMS to 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

50. Fluid Challenges