Penetrating Trauma

ECRN Mod II 2010 CE Condell Medical Center EMS System

IDPH Site code #107200E-1210
Prepared by: Lt. William Hoover, Medical Officer Wauconda Fire District Reviewed/revised by: Sharon Hopkins, RN, BSN, EMT-P

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
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Objectives contd
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
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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 of intraosseous infusion Calculate pediatric fluid challenge dosages

Gunshots

Gunshot Victims

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

Perforating Gunshots

Penetrating gunshot

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 than shotgun bullets Different size of casing provides more or less gunpowder

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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
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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 patients 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 performance handgun 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 initially stabilize these wounds?

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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
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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
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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
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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
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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 Pneumothorax chest decompression Suction to keep airway open Intubate to secure the airway

Surgery is the answer to critical gunshots

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Field Management Goals

Focus on the basics If there is a hole plug it If there is bleeding stop it If they cant breathe ventilate

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Region X

Field Triage Criteria For Assessing Trauma Patients

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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

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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 option especially 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

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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
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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
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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 as much 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 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
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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
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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 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!

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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 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
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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 thrown into 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 & head immobilizers 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 volume procedure

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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 attempts or 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 fall dependently
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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)
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Equipment Case
EZ connect tubing

10 ml syringe with saline

Needle sizes used in Region X

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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

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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 additional sites These additional sites may be accessed by MD inserting IO needle

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
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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 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
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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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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 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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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
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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 of adding this extension tubing to all IV starts

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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
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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 begin fluid therapy

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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

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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. Patient c/o pain during IVP and medication delivering continued anyway.
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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
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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 through the hole

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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
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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 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
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Case Study #3
What injuries do you anticipate knowing entry point and angle of impalement?

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Case Study #3
Initial assessment performed to identify life threats Airway open Breathing without distress although patient is upset Circulation warm & dry; capillary refill 1 seconds; pulse steady and palpable at the radial site Disability & disrobe AVPU awake, cooperative, anxious
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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

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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
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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
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Case Study #4
EMS 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 What is first things first? SAFETY, SAFETY, SAFETY
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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

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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
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Case Study #4
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)

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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
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 You cant assess what you cant see remove clothing What injuries do you anticipate?
Heart, lung, vessels Trachea Esophagus

Case Study #5

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 from the field Proper stabilization of the object to prevent further damage by movement Rapid OR for direct visualization and repair
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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 contd
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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