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1 Penetrating Trauma ECRN Mod II 2010 CE Condell Medical Center EMS System IDPH Site code #107200E-1210 Prepared by: Lt. William Hoover, Medical Officer.

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Presentation on theme: "1 Penetrating Trauma ECRN Mod II 2010 CE Condell Medical Center EMS System IDPH Site code #107200E-1210 Prepared by: Lt. William Hoover, Medical Officer."— Presentation transcript:

1 1 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

2 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 3 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

4 4 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

5 5 Gunshots…

6 6 Gunshot Victims

7 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 8 Perforating Gunshots

9 9 Penetrating gunshot

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

11 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 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 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 14 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

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

16 16 Pistols – Medium Velocity

17 17 Shotguns – Medium Velocity

18 18 Rifles – High Velocity

19 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 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 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 patients injuries

22 22 Shotgun Shell – Medium Velocity 12 Gauge Shotgun Slug12 Gauge Shotgun with #6 shot

23 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 24 Compound Bows and Arrows – Medium Velocity

25 25 Arrowhead Types – Medium Velocity Target tipsBroadhead

26 26 Arrow injuries

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

28 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 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 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 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 32 Police Officer Stabbing What injuries do you suspect?

33 33 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

34 34 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)

35 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 36 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

37 37 Region X Field Triage Criteria For Assessing Trauma Patients

38 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 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 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 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 29 – Revised trauma score < 11 Range 0-12 – 3 components added together » Converted GCS (3-15 score converted to 0-4 points) » points for respiratory rate » points for systolic blood pressure

42 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 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 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 45 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

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

47 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 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 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 50 Fluid Challenges

51 51 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 body will cause core body temperature to decrease – Hypothermia results – Cold patients become acidotic patients

52 52 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

53 53 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

54 54 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!

55 55 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

56 56 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

57 57 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

58 58 Case Study #1 EMS dispatched for double 0942 Ambulance 0942 Ambulance 0947 Flight for Life 0952 Scene secured by 1000 FFL in the 1000 Patient contact

59 59 Case Study #1 Ambulance enroute to landing 10:13 FFL on 10:15 FFL to Level 10:23.38 caliber revolver pistol used in the shooting

60 60 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)

61 61 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 110

62 62 Case Study #1 Respirations 22 with SPO 2 of 94% on room air – S P O 2 increased to 99% after 15 L via NRB ECG: Sinus tachycardia with rate of 110 Patient disoriented GCS = 9; RTS = 10

63 63 Case Study #1 Treatment plan: – Scene safety (field and in ED) – ABCs performed – Rapid transport with early communication to receiving facility – Supplemental O 2, IV enroute, monitor – Immobilization by c-collar, backboard & head immobilizers – Patient needs to be exposed for evaluation of multiple gunshot wounds

64 64 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

65 65 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

66 66 EZ IO Have you used one on a patient or cared for a patient with one? High risk, low volume procedure

67 67 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

68 68 EZ IO Contraindications – Fracture of the tibia or femur – Infection at insertion site – Previous orthopedic procedure (knee replacement, previous IO insertion within 48 0 ) – 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

69 69 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)

70 70 Equipment Case Needle sizes used in Region X EZ connect tubing 10 ml syringe with saline

71 71 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 90 0 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

72 72 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

73 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

74 74 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

75 75

76 76 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

77 77 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

78 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) 78 Region X SOP - Saline Lock

79 79 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

80 80 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

81 81 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

82 82 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

83 83 Improperly Secured IV Site Insertion site taped over Gauze bandaging under tape – Increased risk of infection IV site properly covered with see through dressing

84 84 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.

85 85 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

86 86 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 3 rd intercostal space – No air seems to be moving through the hole

87 87 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

88 88 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; SpO 2 98%; warm & dry No active bleeding

89 89 Case Study #3 What injuries do you anticipate knowing entry point and angle of impalement?

90 90 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 ½ seconds; pulse steady and palpable at the radial site – Disability & disrobe AVPU – awake, cooperative, anxious

91 91 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

92 92 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

93 93 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

94 94 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

95 95 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

96 96 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

97 97 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, O 2, monitor)

98 98 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

99 99 Case Study #5 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

100 100 Case Study #5 – Operative View Impaled object after removal Was near pulmonary artery but no damage Knife missed all vital structures

101 101 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

102 102 Bibliography Hoover, C. Fluid Resuscitation Controversies. EMS Magazine. March Proehl, J. Emergency Nursing Procedures, 4 th Edition. Saunders Region X SOP March 2007; amended January 1, Smith, M. Lecture. Working Together EMS Conference Wauconda Fire Department call records

103 103 Bibliography contd

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