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Gun Shots & Stabbings - An introduction to the management of pre-hospital trauma patients
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Transcript of Gun Shots & Stabbings - An introduction to the management of pre-hospital trauma patients
By Dr. Nic Sparrow MBBS, BSc, MRCGP
Medical Director – Pre-Hospital Care Worldwww.phcworld.org
To discuss some of the general principles of managing penetrating trauma in the pre-hospital setting
Look at some of the common injuries
Review some essential interventions and skills needed to treat patients
THINK SAFETY - SELF... Scene... and Survivors
Plan your route, make a slow & safe approach / park defensively. Await the arrival of the police...
Communicate arrival to control & other services
Assess & Approach only if it is safe (remember it’s a crime scene – don`t become a casualty)
Pre-Hospital Care (PHC) Provider
Airway Breathing Circulation Disability Exposure
Assessment is often done simultaneouslyAlways remember C-spine & Massive Haemorrhage Control
Ask yourself
1) What is the diagnosis ?2) How severe is it ?3) Can it be reversed ?4) Is reversal needed now ?
PHC PROVIDER
Rapid Assessment of the Airway / C-spine is required
Remember C-spine / Massive Haemorrhage Control may pose an immediate threat to life and may need to take priority before airway Bullet lodged
close to the cervical spine
‘Penetrating extremity trauma can quickly lead to Massive Haemorrhage and death’
A Useful Piece of Pre-Hospital Equipment:
- The CAT tourniquet can be used to control massive haemorrhagic loss in
stabbed or shot patients
PHC PROVIDER
•SECURE THE C-SPINE
INSPECT FOR:-
•FOREIGN BODIES •FACIAL / MANDIBULAR #’S•TRACHEAL / LARYNGEAL #’S•EXPANDING HAEMATOMAS
ALL CAN LEAD TO AIRWAY OBSTRUCTION AND DEATH
Consider the risks of Air Embolus in vascular injuries to the neck
Inspect the mouth / clear the airway / head tilt chin lift or jaw thrust
Airway interventions depend upon the patient`s injuries, the level of skill and equipment of the provider:-
1. Oxygen 15L (Reservoir Bag)2. Oropharyngeal airway3. Nasopharyngeal airway4. Extraglottic Devices5. Endotracheal intubation 6. Emergency Cricothyroidotomy
A definitive airway should be considered in patients with:-
- GCS of 8 or below
- Unstable #’s of mandible / maxilla- Inhalational burns- Tracheal or laryngeal injury - Penetrating injuries to the neck
with expanding hematoma etc.
Indicated when:-Can’t ventilate / Can’t Intubate
Sedate Patient Scalpel 1cm Stab incision into the
cricothyroid membrane Insert Size 5-6 ET tube Secure the ET tube
Definitive Tracheostomy will be required
PHC Provider
Inspection – Tracheal position, distended neck veins, chest movement, respiratory rate
Auscultation – Air entry, breath sounds, vocal fremitus
Percussion – Dull / hyperesonant
Measure – Respiratory rate & O2 saturations
Life threatening conditions include:- ( ATOMIC – TAO )
Airway obstruction
Tension pneumothorax
Open pneumothorax
Massive Haemothorax
Instability of chest wall (flail Chest & contusions)
Cardiac Tamponade
Tracheal or Bronchial Injury
Aortic / Oesophageal Rupture
‘Posterior stab wound – what might you expect to see on x-ray ? ’
Right Sided Pneumothorax
Consider other possible Structures Injured e.g. oesophagus
Large Right Haemothorax
Haemorrhage is the predominant cause of preventable post-injury deaths. 90% of shock is haemorrhagic in trauma
↓ GCS can be caused by ↓ cerebral perfusion secondary to haemorrhagic shock
Important to consider all possible injuries to organs or vessels in penetrating trauma
Observation – inspect the scene and estimate blood loss, assess colour / temperature of the patient
Palpation – feel for peripheral pulses / strength, character and rate
Auscultation – heart sounds ? muffled
Check Manual Blood pressure on non-injured side
Insert x2 large bore IV’s 14 – 16G
Do not place IV’s on the same side as the injury if possible
Intraosseous / sternal / femoral / central access may be required in the profoundly shocked patient
FLUID RESUSCITATION:
STAGE 1
X2 RINGERS LACTATEMAX (2000 ML)
STAGE 2
X4 GELOFUSINMAX (2000 ML)
BLOOD SHOULD BE GIVEN AFTER STAGE 1 IF AVAILABLE Maintain BP at no more than 90mmHg in
penetrating injuries
Never forget pelvic fractures as a cause for
hypotension
Beware the ‘thirsty’
patient
Blood on the floor
Look for 4 more
(Chest / Abdomen /
Pelvis / Femur)
DISABILITY
AVPU Scoring Assess the GCS Pupils Neurological Deficit
EXPOSURE
Remove clothing (save for forensics)