Presentation on theme: "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 Penetrating Trauma ECRN Mod II 2010 CE Condell Medical Center EMS System IDPH Site code #107200E-1210Prepared by: Lt. William Hoover, Medical OfficerWauconda Fire DistrictReviewed/revised by: Sharon Hopkins, RN, BSN, EMT-P
2 Objectives Identify epidemiologic facts for firearm related injuries Upon successful completion of this module, the ECRN will be able:Identify epidemiologic facts for firearm related injuriesIdentify relationship between kinetic energy and prediction of injuryIdentify how energy is transmitted from a penetrating object to body tissueIdentify characteristics of handguns, shotguns and riflesIdentify organ injuries associated with gunshot injuries
3 Objectives cont’dIdentify management goals for a patient with gunshot woundsIdentify items that could cause stab/penetration traumaIdentify potential internal organ injuries dependant on item causing stab/penetration injuryIdentify management goals for a stab/penetrating trauma patientIdentify adult fluid challenge issues
7 Firearm Related Injuries Gunshot wounds are either penetrating or perforating woundsTechnical 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
10 Entrance woundSurrounded by a reddish-brown area of abraded skin, known as the abrasion ringSmall amounts of blood
11 Mechanism of Energy Exchange As bullet passes through tissue, it decelerates, dissipating and transferring kinetic energy to tissuesCause of the injury is the kinetic energyVelocity more important than mass in determining how much damage is doneSmall bullet at high speed will do more damage than large bullet at slow speed
12 Mechanism of Energy Exchange High velocityHigh powered rifles; hunting riflesSniper riflesMedium velocityHandguns, shotgunsCompound bows and arrows (higher energy released)Low velocityKnives, arrowsFalling through plate glass window, stepping on things, bits flung by lawnmowerCompound bows and arrows are more sophisticated than regular bows and arrows and produce higher energy which makes them a medium velocity weapon.
13 Medium & High VelocityThese items are usually propelled by gunpowder or other explosiveFaster the object, the deeper the injuryCauses damage to the tissue it impactsCreates a “pressure wave” which causes damage frequently greater than the tissue directly impactedIf bone is struck, bone shatters and multiple bone fragments are dispersedThe focus of EMS is not so much to worry about “what kind of bullet was used” but to focus on the injury at hand to take care of. If the bullet type is known, it is just another piece of information passed onto the hospital staff. EMS should focus on “taking care of the hole”.
14 Low velocityUsually a result of items such as knives that are propelled by a person’s own powerAlso includes objects inadvertently stepped onIncludes many objects a patient may be impaled onDamage usually limited to the area directly in contact with the object
19 Projectiles – High Velocity Rifle bullets are designed to have much greater velocity than shotgun bulletsDifferent size of casing provides more or less gunpowder
20 7 mm rifle shell – High Velocity Bonded design for deep penetration and 90%+ weight retentionStreamlined design delivers ultra-flat trajectoriesDevastating terminal performance across a wide velocity rangeUnequaled accuracy and terminal performance for long-range shots
21 Projectiles – Medium Velocity Shotgun ammunition can be a variety of kindsSlugs are one large bullet in the shellSome shells contain numerous pellets of various sizesThis can influence patient’s injuries
22 Shotgun Shell – Medium Velocity 12 Gauge Shotgun Slug12 Gauge Shotgun with #6 shot
23 .38 caliber pistol ammunition Controlled expansion to 1.5x its original diameter over a wide range of velocitiesHeavier jacket stands up to the high pressures and velocities of the highest performance handgun cartridges
27 Another ouch…. How would you initially stabilize these wounds? Goals of treatment - to prevent movement of the impaled object and to prevent further contamination. Will most likely need to splint the wrist in some fashion as well as stabilize the object.
28 Principles of Wound Care What are principles of wound care for the two previous wounds?Scene safety – even in the EDControl bleedingUsually little to no bleeding while object still impaledPrevent further damageImmobilize the object in placeGauze, tape, whatever it takesReduce infectionPrevent further contamination
29 Different Types of Knives Knives come in a wide variety of shapes and sizesThe type of knife can influence the injuries a patient may haveHilt/handle of knife does not necessarily tell how long the knife is
30 Anticipation of Injury Trajectory may or may not be straightKnowing anatomy helps anticipate organ injuryAnticipating organ injury helps in knowing what signs and symptoms to watch forAnticipation of injury = proactive careHead wound = monitoring level of consciousnessChest wound = assessing lung soundsAbdominal 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 internallyAssume the worseStabilization of impaled objects extremely crucial
32 Police Officer Stabbing What injuries do you suspect? Evaluate for chest and abdominal injuries. Not knowing depth or trajectory of stabbing implement, can have organ injury that is angled away from external injury pattern.
33 Organ InjuryLap sponge under fold of skinPatient was shot with a MAC-10 machine gun and sustained a liver injuryLiver 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 SOPDifficult to assess internal damage in the fieldStop any visible bleeding that could cause hemorrhage hypovolemiaAddress airway issuesTension Pneumothorax chest decompressionSuction to keep airway openIntubate to secure the airwaySurgery is the answer to critical gunshots
36 Field Management Goals Focus on the basicsIf there is a hole – plug itIf there is bleeding – stop itIf they can’t breathe – ventilate
37 Region X Field Triage Criteria For Assessing Trauma Patients
38 Field Management Goals Short on scene time! Under 10 minutes!Immediate life threatening issues addressedGood BLS skillsALS treatment while enroute to the hospitalReport called as early as possibleTransport to Level 1 Hospital, if under 25 minutesTransport to closest hospital if Level I >25 minutes awayHelicopter considered in unique situationsHelicopter is a consideration if there is any delay in ground transport being initiated (ie: lengthy extrication). If there is rapid access to the patient there should be minimal scene time and a decision to “load and go” and initiate rapid transport.
39 Patient Transport Decision From the Field Critical and Category I trauma patientsTransported to highest level Trauma Center within 25 minutesAeromedical transport remains an option especially in lengthy extrication and distance from the hospital
40 Field Categorization of the Critical Patient Systolic B/P < 90 x2Pediatric patient B/P < 80 x2Blood pressure values taken at least twice and 5 minutes apartThese patients transported to highest level Trauma Center within 25 minutes
41 Field Categorization of the Category I Trauma Patient Unstable vital signsGCS < 10 or deteriorating mental statusBest eye opening – 4 points maxBest verbal response – 5 points maxBest motor response – 6 points maxRespiratory rate <10 or >29Revised trauma score < 11Range 0-123 components added togetherConverted GCS (3-15 score converted to 0-4 points)0 - 4 points for respiratory rate0 - 4 points for systolic blood pressure
42 Field Categorization of the Category I Trauma Patient Anatomy of injuryPenetrating injuries to head, neck, torso, or groinCombination trauma with burns > 20%2 or more proximal long bone fracturesUnstable pelvisFlail chestLimb paralysis &/or sensory deficits above wrist or ankleOpen and depressed skull fracturesAmputation proximal to wrist or ankleLanguage for skull fractures changing to open OR depressed skull fractures.
43 Patient Transport Decision From the Field Category II trauma patientsTransported to closest Trauma CenterThese are stable patients with significant mechanism of injuryYou know they are stable because of frequent reassessmentThere is the potential for these patients to become unstableRecognize 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 injuryEjection from automobileDeath in same passenger compartmentMotorcycle crash >20 mph or with separation of rider from bikeRollover – unrestrainedFalls > 20 feetPeds falls > 3x body lengthResearch has shown that the restrained patient in a rollover is rarely injured. If they are injured critically, their physiological parameters (ie: LOC, vital signs) would push them into the higher Category I level.
45 Category II Trauma Patient cont’d Mechanism of injury cont’dPedestrian thrown or run overAuto vs pedestrian / bicyclist with > 5 mph impactExtrication > 20 minutesHigh speed MVCSpeed > 40 mphIntrusion > 12 inchesMajor deformity > 20 inches
46 Category II Trauma Patient Co-morbid factorsAge < 5 without car/booster seatBleeding disorders or on anticoagulantsPregnancy > 24 weeks
47 Category III Trauma Patient All other patients presenting with traumatic injuriesFracturesSprains/strainsBurnsFallsPainProvide routine trauma careHonor patients request for hospital choice as much as possible
48 Field to Hospital Communication EMS to call early; update as neededGives time for hospital staff and resources to be mobilizedThe more critical the patient, most likely the shorter the reportImportant details to be givenHead to toe picture needs to be paintedJust as important to give tasks not completedIntubation versus baggingIV access obtained or not
49 Abbreviated Radio Report Department name, vehicle number and receiving hospitalEMS to state, “this is an abbreviated report”Provide nature of situation and SOP being followedAge and sex of patientChief complaint and brief historyAirway and vascular statusCurrent vital signs, GCSMajor interventions completed or being attemptedETAProvided to Medical Control in situations where manpower is limited and / or the patient’s condition is critical.
51 Adult Fluid ChallengeAdult fluid replacement is in 200 ml increments (replacement formula 20 ml/kg)Storage issuesIV bags are usually in ambulance, in baysFluid eventually are at ambient temperatures70° fluid into body will cause core body temperature to decreaseHypothermia resultsCold patients become acidotic patientsBody functions and response to medications less reliable in acidotic (and hypoxic) environment.
52 Adult Fluid Challenge 200 ml increments Formula is 20 ml/kg Example 200 # patient = 100 kg100 kg x 20 ml/kg = 2000ml fluid challengeReassess your patient as you are passing the ml markMonitor breath sounds for fluid overload
53 Adult Fluid Challenges Vascular issuesVessel damage results in extensive blood lossEMS infuses Normal SalineNS does not carry oxygen; NS solves volume issue onlyVolume 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 Adult Fluid Challenges If your patient’s blood is becoming pink (ie: not red), they need more blood in the system!EMS typically does not carry blood in the fieldImportant 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 Pediatric Fluid Challenges Pediatric shock protocolEMS carries Normal SalineFormula for fluid challenge is 20 ml per kgCan be administered up to three times total or up to 60 ml per kg totalSmaller container (patient size) means less fluid means less oxygen carrying capacityExample:30# patient = 14 kg (30 2.2)14 x 20ml/kg = 280 ml fluid challengeFluid challenges are based on the patient’s weight. Frequent reassessment is required as you move toward your total calculated fluid challenge amount.
56 Fluid Challenge Calculation Practice 6 year old patient weighs 66 pounds66 pounds = 30 kgFluid challenge of 30 kg x 20 ml = 600 ml each time15 year old patient weighs 175 pounds175 pounds = 80 kgFluid challenge of 80 x 20ml = 1600 ml fluid25 year old patient weighs 120 poundsAdult gets fluid challenge in 200 ml increments75 year old patient weighs 180 poundsAdult gets cautious fluid challenge in 200 ml incrementsFrequently monitor breath sounds to make sure patient can handle the fluid being infused. As a rule of thumb for the pediatric patient, if they need one fluid challenge, anticipate that they would need at least 2.Pediatric fluid challenge amounts are usually well above the “200 ml” incremental mark EMS thinks about for the adult.
57 Fluid Challenges Precautions All patients need to be monitored for potential CHFEven a previously healthy patient can be thrown into CHFToo much fluid too fast
58 Case Study #1 EMS dispatched for double shooting @ 0942 Ambulance 0942Ambulance 0947Flight for Life 0952Scene secured by 1000FFL in the 1000Patient contact
59 Case Study #1 Ambulance enroute to landing zone @ 10:13 FFL on 10:15FFL to Level 10:23.38 caliber revolver pistol used in the shooting
60 Case Study #1Patient #138 year-old female with multiple gun shot woundsFound in the basement of the houseGSW 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 Case Study #1 Patient #1 cont’d Approximately 2 liters of blood loss Responding to verbal stimuliPupils: PERLLungs: left (clear), right (rhonchi), normal effortSkin: Pale, dry, cool with delayed capillary refillPast medical history, meds & allergies unknownUnable to obtain B/P, femoral 110
62 Case Study #1 Respirations 22 with SPO2 of 94% on room air SPO2 increased to 99% after 15 L via NRBECG: Sinus tachycardia with rate of 110Patient disorientedGCS = 9; RTS = 10
63 Case Study #1 Treatment plan: Scene safety (field and in ED) ABC’s performedRapid transport with early communication to receiving facilitySupplemental O2, IV enroute, monitorImmobilization by c-collar, backboard & head immobilizersPatient needs to be exposed for evaluation of multiple gunshot wounds
64 Case Study #1Bleeding controlled to entry & exit wounds with trauma dressingsOxygen administered at 15 L via NRB maskIV of Normal Saline administered with 18 G in left extremity, wide open rateEMS crew monitored lung sounds and femoral pulses throughout callPatient transferred to FFL crewCMC (as Medical Control) notified
65 Case Study #1 Is this a Category I or II trauma patient and why? Systolic B/P below 90GCS less than 10RTS less than 11Penetrating injuries to head, neck, torso or groinCategory I trauma patient
66 EZ IO Have you used one on a patient or cared for a patient with one? High risk, low volume procedure
67 EZ IO Field indications Must meet all indications Shock, arrest, or impending arrestUnconscious/unresponsive to verbal stimuli2 unsuccessful IV attempts or 90 seconds duration
68 EZ IO Contraindications Fracture of the tibia or femur Infection at insertion sitePrevious 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
69 EZ IO Equipment Lithium drill Needle EZ connect tubing Syringe Battery powered for 1000 insertionsNeedleBlue 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 tubingSyringeSaline to prime EZ connect tubingPrimed IV bagPressure bag/B/P cuffSite prep material (ie: alcohol pad)
70 Equipment Case EZ connect tubing 10 ml syringe with saline Helpful to keep 2 sets of needles of each size in equipment case – if failed attempt in one site, can attempt the opposite site. Helpful to add 2 IV start kits to the equipment case – then all equipment is available in one kit.Needle sizes used in Region X
71 EZ IO ProcedurePrime EZ connect tubing with saline; leave syringe attached (for flushing)Locate and cleanse siteProximal medial tibiaPrepare driver and needle set; remove safety capInsert needle at 900 angleRemove styletAttach primed EZ connect tubingAspirate then flush line with remaining salineRemove syringe only and connect primed IV setConfirm needle placement
72 Identifying Site Proximal medial tibia 2 finger breadths below patella (to tibial tuberosity) and 1 finger breadth medially from tibial tuberosityMay or may not be able to identify the tibial tuberosity at 2 finger breadths below patellaAs patient is lying supine, legs tend to roll slightly outwardThis presents the flat surface of the tibia
73 EZ IO Sites Proximal medial tibia FYI - Additional sites available Site approved for Region X EMS personnelFYI - Additional sites availableHumeralAnkleOther EMS regions may use these additional sitesThese additional sites may be accessed by MD inserting IO needle
74 Confirming EZ IO Placement Sudden lack of resistance feltNeedle stands up by selfBone marrow may be noted on aspirationNo resistance to flushingIV runs with pressure applied to IV bagNo infiltration noted
76 Documentation OF EZ IO Insertion Document usual IV insertion informationTime of insertionSize IV bag usedSite, needle length, needle gaugeAmount of fluid infused in the fieldPlace fluorescent yellow arm band on patient’s wrist to indicate insertion (or attempt) of IORecommended to place on same side as insertion siteArm band used for successful and unsuccessful insertions
77 Saline Lock/Extension Tubing Field indicationTo establish an extension line between the IV catheter and the IV tubingAllows hospital staff to change IV tubing with less disturbance to the inserted IV catheterTo have access to circulation without the need for fluidsEquipmentIV start pakIV catheterMacrobore extension set (7.25 inches)10 ml saline in syringe for priming tubing and flushingInserting extension tubing will make it easier for the hospital to switch out IV tubing if they need to. Having the extension tubing in place allows manipulation with tubing but will minimize movement of the catheter in the patient. This will discuss the risk of losing the line and decrease the chance of complications from excessive movement.
78 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 patient’s condition and ageMay use a saline lock cap on IV catheter hub for stable patients (not needing fluid resuscitation)
79 “Saline Lock” Procedure Establish an IV following sterile techniqueRemove styletInsert distal tip of primed extension tubing/ saline lock into IV catheterIf administering fluids, IV tubing should be already attached to the extension tubing/saline lockAdjust flow rateIf IV line is precautionary, flush extension tubing/saline lock with 10 ml sterile normal salineRemove syringeDo not need IV tubing or IV bag
80 Extension Tubing/Saline Lock Connecting to IV catheterKeep IV site as distal as possibleAC should not be your first choiceWe are requesting to start getting into habit of adding this extension tubing to all IV starts
81 IV Equipment for Saline Lock If patient needs fluid, attach primed IV tubing with bag to proximal end of extension tubing/saline lockWipe off blue clave port with alcohol prep padPush in and twist primed IV tubing to connectAdjust flow rate as indicatedDocument time, type, and size IV solution hungDistal tip of clave inserted into IV catheter
82 Extension tubing/Saline Lock In Place Extension tubing/saline lock properly securedInsertion site not taped overClear view of insertion site through op-site/tegaderm dressingAccess to port availableCan easily attach primed IV tubing if need to begin fluid therapy
83 Improperly Secured IV Site Insertion site taped overGauze bandaging under tapeIncreased risk of infectionIV site properly covered with seethrough dressing
84 Extravasation of Medication To use the extension tubing/saline lock for infusion, must verify that the line is patentAspirate for blood returnStop infusion if patient complains of pain/burningExtravasation of IVP medication resulting in amputation of several fingers Patient c/o pain during IVP and medication delivering continued anyway.
85 Case Study #2 25 year-old male shot in the chest Police are on the scenePatient sitting on ground, leaning against carSeveral small casings on ground near victimPatient bleeding from small chest wound left anterior chestPatient is anxious, pale, diaphoretic with elevated respiratory rate
86 Case Study #2 Patient alert and oriented x3 Complains of mild chest pain aggravated with deep breathingVS: 122/86, 90 – 20Hole noted in the left anterior chest about the 3rd intercostal spaceNo air seems to be moving through the hole
87 Case Study #2 Interventions required Immediately seal the open wounds Dressing secured on 3 sidesHigh flow oxygen administered via non-rebreatherIV access establishedContact Medical ControlWhat Category trauma is this patient?Category I – penetration of torso
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 awakePatient states she was running out of the house and tripped down the stairsTree branch noted impaled through right flank at level of umbilicusVS: 124/100; 120; 22; SpO2 98%; warm & dryNo active bleeding
89 Case Study #3What injuries do you anticipate knowing entry point and angle of impalement?
90 Case Study #3 Initial assessment performed to identify life threats Airway – openBreathing – without distress although patient is upsetCirculation – warm & dry; capillary refill 1 ½ seconds; pulse steady and palpable at the radial siteDisability & disrobeAVPU – awake, cooperative, anxious
91 Case Study #3 Categorization? Interventions Category I – penetrating object to torsoInterventionsSecure impaled object, prevent further movementManual control initiallyGauze padding around entrance siteAssess for exit wound
92 Case Study #3 What internal injury is anticipated? Abdominal Solid organ – bleedingHollow organ – spilling contents causing contaminationPunctured vessels hemorrhageChestPunctured diaphragmPunctured lungPunctured heartPunctured vessels
93 Case Study #3 Follow-up Patient taken to OR Stabilization maintained to prevent movement of impaled objectTree branch removed under direct visualizationAbdominal cavity cleaned and flushedPatient did well and was discharged 5 days post-op
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 headPatient is breathing, radial pulse is palpableThey do not open their eyes; the patient moans when touched; the patient withdrawsWhat is first things first?SAFETY, SAFETY, SAFETY
95 Case Study #4 Need to log roll patient protecting C-spine Maintain clear airwayGCSEye opening – 1Verbal response – 2Motor response – 4Total GCS - 7
96 Case Study #4 Cannot tell internal damage by external appearances only Patient had small bone fragments that were pushed into the brainPatient required neurosurgery evaluation
97 Case Study #4 Report from EMS Description of wound(s) noted including body regionType of weapon used if information is availableDistance from weapon if availableCloser the range, the more energy that is behind the bullet/shot the greater the internal damageNote basic care provided (IV, O2, monitor)
98 Case Study #5 A patient presents as a walk-in to your facility Approximately 2 hours ago, he was involved in a domestic disturbancePatient states his girlfriend hit him in the upper chest and he continues to have some pain and is now worried regarding the injuryAwake and alert, vital signs stableDried blood noted on upper chest wall midline
99 Case Study #5 You can’t assess what you can’t see – remove clothing What injuries do you anticipate?Heart, lung, vesselsTracheaEsophagusVisible woundPatient states he doesn’t know what he was hit with. Patient was aware of blood on his clothes after the confrontation.Object viewed on x-ray
100 Case Study #5 – Operative View Impaled object after removalWas near pulmonary artery but no damageKnife missed all vital structures
101 Case ClosureWhat saves lives when impaled/penetrating objects are involved?Age and condition of patientYounger patients and those in good health can tolerate the insult betterRapid identification and transport from the fieldProper stabilization of the object to prevent further damage by movementRapid OR for direct visualization and repair
102 BibliographyHoover, C. Fluid Resuscitation Controversies. EMS Magazine. March 2010.Proehl, J. Emergency Nursing Procedures, 4th Edition. SaundersRegion X SOP March 2007; amended January 1, 2008.Smith, M. Lecture. “Working Together” EMS Conference 2010.Wauconda Fire Department call recordsOlliver.family.gen.nz/launchpad/Head_wound.png