ECRN Mod II 2010 Penetrating Trauma

7/29/2019 ECRN Mod II 2010 Penetrating Trauma

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Penetrating Trauma

ECRN Mod II 2010 CE

Condell Medical Center EMS System

IDPHSite code #107200E-1210

Prepared by: Lt. William Hoover, Medical OfficerWauconda Fire District

Reviewed/revised by: Sharon Hopkins, RN, BSN, EMT-P


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Objectives

Upon successful completion of this module, the ECRNwill be able:

Identify epidemiologic facts for firearm relatedinjuries

Identify relationship between kinetic energy andprediction of injury

Identify how energy is transmitted from apenetrating object to body tissue

Identify characteristics of handguns, shotguns andrifles

Identify organ injuries associated with gunshotinjuries


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Objectives contd

Identify management goals for a patient with gunshotwounds

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


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Objectives contd

Identify adult fluid challenge dosages

Identify pediatric fluid challenge issues

Identify pediatric fluid challenge dosages

Identify indications for implementation ofintraosseous infusion

Calculate pediatric fluid challenge dosages


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Gunshots


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Gunshot Victims


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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 bulletenters and exits the body


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Perforating Gunshots


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Penetrating gunshot


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Entrance wound

Surrounded by a

reddish-brown area

of abraded skin,

known as the

abrasion ring

Small amounts of

blood


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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


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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


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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


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Low velocity

Usually a result of items such as knives that

are propelled by a persons 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


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Types of Firearms

Pistols

Revolver

Semi-Automatic

Shotguns Pump

Semi-Automatic

Rifles Bolt

Lever action


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Pistols Medium Velocity


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Shotguns Medium Velocity


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Rifles High Velocity


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Projectiles High Velocity

Rifle bullets are

designed to have

much greater

velocity thanshotgun bullets

Different size of

casing provides

more or lessgunpowder


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7 mm rifle shell High Velocity

Bonded design for deeppenetration and 90%+weight retention

Streamlined design

delivers ultra-flattrajectories

Devastating terminalperformance across awide velocity range

Unequaled accuracy andterminal performance forlong-range shots


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Projectiles Medium Velocity

Shotgun ammunitioncan be a variety of kinds

Slugs are one largebullet in the shell

Some shells containnumerous pellets ofvarious sizes

This can influencepatients injuries


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Shotgun Shell Medium Velocity

12 Gauge Shotgun Slug 12 Gauge Shotgun with #6 shot


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.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 performancehandgun cartridges


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Compound Bows and Arrows

Medium Velocity


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Arrowhead Types Medium Velocity

Target tips Broadhead


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Arrow injuries


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Another ouch.

How would

you initiallystabilize

these

wounds?


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Principles of Wound Care

What are principles of wound care for the twoprevious wounds?

Scene safety even in the ED

Control bleeding

Usually little to no bleeding while object stillimpaled

Prevent further damage

Immobilize the object in placeGauze, tape, whatever it takes

Reduce infection

Prevent further contamination


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Different Types of Knives

Knives come in a wide

variety of shapes and

sizes

The type of knife caninfluence the injuries a

patient may have

Hilt/handle of knife

does not necessarily tell

how long the knife is
http://www.aceros-de-hispania.com/gb/infer.asp?ac=1&trabajo=listar&pa=cuchillos_machetes_knives&sg=cuchillos_machetes_knives


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Anticipation of Injury

Trajectory may or may not be straight

Knowing anatomy helps anticipate organinjury

Anticipating organ injury helps in knowingwhat 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


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Stabbings

15 year old stabbed in

the head at a London

bus stop

Cannot determine fromthe outer wound what

the damage is internally

Assume the worse

Stabilization of impaled

objects extremely

crucial
http://1.bp.blogspot.com/_FVyp9i1Vtus/SOK-PMFc-gI/AAAAAAAABxQ/Znca9qWb570/s1600-h/xray.jpg


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Police Officer Stabbing

What injuries do you suspect?


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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


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Scene Safety

Not exclusive to schools

Fort Hood, TX Shooting (2009)

Colorado Church Shootings (2007)

Queens, NY Wendys Shooting (2000)

Atlanta Day Trader Shooting (1999)

San Ysidro McDonalds Shooting (1984)


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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 Pneumothoraxchest decompression

Suction to keep airway open

Intubate to secure the airway

Surgery is the answer to critical gunshots


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Focus on the basics

If there is a hole plug itIf there is bleeding stop it

If they cant breathe ventilate


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Region X

Field Triage Criteria For AssessingTrauma Patients


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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


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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 optionespecially in lengthy extrication and

distance from the hospital


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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

Field Categorization of the Category I


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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 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


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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 orankle

Open and depressed skull fractures

Amputation proximal to wrist or ankle


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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


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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


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Category II Trauma Patient contd

Mechanism of injury contd

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


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Category II Trauma Patient

Co-morbid factors

Age < 5 without car/booster seat

Bleeding disorders or on anticoagulants

Pregnancy > 24 weeks


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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 asmuch as possible


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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 theshorter 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


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Abbreviated Radio Report

Department name, vehicle number and receivinghospital

EMS to state, this is an abbreviated report

Provide nature of situation and SOP being

followedAge and sex of patient

Chief complaint and brief history

Airway and vascular status

Current vital signs, GCS

Major interventions completed or beingattempted

ETA


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Fluid

Challenges


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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


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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


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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 deficit can be filled, but patient still in

distress due to lack of oxygen carrying capacity (ie:patient needs blood)

Goal should not be to get a 120/80 blood

pressure, rather to stabilize


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Adult Fluid Challenges

If your patients blood is becoming pink (ie:not red), they need more blood in the system!

EMS typically does not carry blood in the field

Important to accelerate transport to a facilitythat can add the blood and do the surgery torepair the underlying problem!!!

Good BLS skills are more important than ALSskills for these types of patients!


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Pediatric Fluid Challenges

Pediatric shock protocol EMS carries Normal Saline

Formula for fluid challenge is 20 ml per kg

Can be administered up to three times total or upto 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

Fl id Ch ll C l l ti P ti


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Fluid Challenge Calculation Practice

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


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Fluid Challenges

Precautions

All patients need to be monitored for potential

CHF

Even a previously healthy patient can be throwninto CHF

Too much fluid too fast


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Case Study #1

EMS 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 made @1002


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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


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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)


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Case Study #1

Patient #1 contd

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


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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


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Case Study #1

Treatment plan:

Scene safety (field and in ED)

ABCs performed

Rapid transport with early communication to

receiving facility

Supplemental O2, IV enroute, monitor

Immobilization by c-collar, backboard & headimmobilizers

Patient needs to be exposed for evaluation of

multiple gunshot wounds


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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

EMS crew monitored lung sounds and femoral

pulses throughout call

Patient transferred to FFL crew

CMC (as Medical Control) notified


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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

Category I trauma patient


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EZ IO

Have you used one on a

patient or cared for a

patient with one?

High risk, low volumeprocedure


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EZ IO

Field indications

Must meet all indications

Shock, arrest, or impending

arrest

Unconscious/unresponsive

to verbal stimuli

2 unsuccessful IV attemptsor 90 seconds duration


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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 falldependently

EZ IO Equipment


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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)

Equipment Case


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Equipment Case

Needle sizes used in Region X

EZ connect tubing

10 ml syringewith saline


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EZ IO Procedure

Prime EZ connect tubing with saline; leave syringeattached (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


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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


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EZ IO Sites

Proximal medial tibia Site approved for Region X EMS personnel

FYI - Additional sites available

Humeral Ankle

Other EMS regions may use these additionalsites

These additional sites may be accessed by MDinserting IO needle


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Confirming EZ IO Placement

Sudden lack of resistancefelt

Needle stands up by self

Bone marrow may benoted on aspiration

No resistance to flushing

IV runs with pressureapplied to IV bag

No infiltration noted


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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 patients wristto indicate insertion (or attempt) of IO

Recommended to place on same side as insertion

site Arm band used for successful and unsuccessful

insertions

Saline Lock/Extension Tubing


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Saline Lock/Extension Tubing

Field 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


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Routine medical care SOP states:

Establish 0.9 normal saline (NS) per IV/IO and

adjust flow as indicated by the patients condition

and age May use a saline lock cap on

IV catheter hub for stable

patients (not needing fluid

resuscitation)

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Region X SOP - Saline Lock

Saline Lock Procedure


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Saline Lock Procedure

Establish an IV following sterile technique

Remove stylet

Insert distal tip of primed extension tubing/ salinelock into IV catheter

If administering fluids, IV tubing should be alreadyattached to the extension tubing/saline lock

Adjust flow rate

If IV line is precautionary, flush extensiontubing/saline lock with 10 ml sterile normal saline

Remove syringe

Do not need IV tubing or IV bag

b / l k


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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 ofadding this extension tubing to all IV starts

IV Equipment for Saline Lock


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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

i bi / li k l


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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 beginfluid therapy

I l S d IV Si


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Improperly Secured IV Site

Insertion site taped over

Gauze bandaging under tape

Increased risk of infection

IV site properly covered with see

through dressing

E i f M di i


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Extravasation of Medication

To use the extension tubing/saline lock forinfusion, must verify that the line is patent

Aspirate for blood return

Stop infusion if patient complains of pain/burning

Extravasation of IVPmedication resulting in

amputation of several fingers.Patient c/o pain during IVPand medication deliveringcontinued anyway.

C St d #2


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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

C St d #2


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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 throughthe hole

C St d #2


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Case Study #2

Interventions required

Immediately seal the open wounds

Dressing secured on 3 sides

High flow oxygen administered via non-rebreather

IV access established

Contact Medical Control

What Category trauma is this patient?Category I penetration of torso

C St d #3


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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 groundconscious and awake

Patient states she was running out of the house andtripped down the stairs

Tree branch noted impaled through right flank atlevel of umbilicus

VS: 124/100; 120; 22; SpO2 98%; warm & dry

No active bleeding

C St d #3


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Case Study #3

What injuries do youanticipate knowing

entry point and angle

of impalement?

C St d #3


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Case Study #3

Initial assessmentperformedto identify life threats

Airway open

Breathing without distress although patientis upset

Circulation warm & dry; capillary refill 1 seconds; pulse steady and palpable at the

radial site

Disability & disrobe

AVPU awake, cooperative, anxious

C St d #3


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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

Case Study #3


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Case Study #3

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

Case Study #3 Follow up


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Case Study #3 Follow-up

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

Case Study #4


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y

EMS responded to a call at a tavern for a personshot

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 What is first things first?

SAFETY, SAFETY, SAFETY

Case Study #4


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Case Study #4

Need to log roll patientprotecting C-spine

Maintain clear airway

GCS Eye opening 1

Verbal response 2

Motor response 4

Total GCS - 7


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Case Study #4


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y

Report from EMS

Description of wound(s) noted including body

region

Type of weapon used if information is available

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)

Case Study #5


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Case Study #5

A patient presents as a walk-in to your facility

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

Dried blood noted on upper chest wall midline

Case Study #5


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y You cant assess what you cant see remove

clothing

What injuries do you anticipate? Heart, lung, vessels

Trachea

Esophagus

Visible wound

Object viewed on x-ray

Case Study #5 Operative View


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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

Case Closure


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Case Closure

What saves lives when impaled/penetratingobjects are involved?

Age and condition of patient

Younger patients and those in good health cantolerate the insult better

Rapid identification and transport from thefield

Proper stabilization of the object to preventfurther damage by movement

Rapid OR for direct visualization and repair

Bibliography


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Bibliography

Hoover, C. Fluid Resuscitation Controversies. EMSMagazine. 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 Conference2010.

Wauconda Fire Department call records

Olliver.family.gen.nz/launchpad/Head_wound.png

www.cabelas.com

www.jems.com

Bibliography contd


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Bibliography cont d

www.remington.com www.vidacare.com

www.Wikipedia.org

www.winchester.com
http://www.vidacare.com/http://www.vidacare.com/

ECRN Mod II 2010 Penetrating Trauma

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