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1 Gunshots, Stabbings and Other Nefarious Acts… April 2010 CE Condell Medical Center EMS System Prepared by: Lt. William Hoover, Medical Officer Wauconda.

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Presentation on theme: "1 Gunshots, Stabbings and Other Nefarious Acts… April 2010 CE Condell Medical Center EMS System Prepared by: Lt. William Hoover, Medical Officer Wauconda."— Presentation transcript:

1 1 Gunshots, Stabbings and Other Nefarious Acts… April 2010 CE Condell Medical Center EMS System Prepared by: Lt. William Hoover, Medical Officer Wauconda Fire District Reviewed/revised by: Sharon Hopkins, RN, BSN, EMT-P Revised 4.12.10

2 2 Objectives Upon successful completion of this module, the EMS provider 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 cont’d 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 cont’d Identify adult fluid challenge dosages Identify pediatric fluid challenge issues Identify pediatric fluid challenge dosages Identify procedures for implementation of intraosseous infusion Demonstrate implementation of intraosseous infusion Demonstrate insertion of a saline lock Demonstrate calculation of pediatric fluid challenge dosage

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 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 person’s 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 patient’s 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 stabilize and dress these wounds?

28 28 Principles of Wound Care What are principles of wound care for the two previous wounds? – Scene safety – 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 be straight or not 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 Attacks at both Columbine and Virginia Tech had well armed offenders EMS and Police must work through a unified command structure to provide maximum safety

35 35 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)

36 36 Management Goals Short on scene time! Under 10 minutes! Immediate life threatening issues addressed Rapid move to ambulance Good BLS skills ALS treatment while enroute Transport to Level 1 Hospital, if under 25 minutes Transport to closest hospital if Level I >25 minutes away Consider helicopter in unique situations

37 37 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

38 38 Management Goals Focus on the basics If there is a hole – plug it If there is bleeding – stop it If they can’t breathe – ventilate

39 39 Scene Management Review Columbine shooting showed areas that police needed to address – Previously philosophy for police was to secure area and wait in perimeter for SWAT to arrive – But, this allowed shooter to continue unobstructed – Police now form team early and enter the building to engage shooter providing containment – Prevents shooter from continuing rampage

40 40 Thoughts - Scene Management EMS/Fire has not been as proactive Staging vs. Entry – Some agencies are sending first patrol officers in to engage/contain offender – Next group in is two medics with two police escorts – Treat patient and move on until running out of supplies, then retreat to remove victims – Provide aggressive care and move fast – Departmental policies need to be reviewed Preferable to review with police input

41 41 Scene Management Use MABAS to get more help early Activate the Multiple Patient Incident Plan Multiple staging areas – Explosives could be set for responders – Easier deployment to variety of areas – Downside is less scene control

42 42 Categorizing The Patient Perform scene size-up Perform initial assessment – Purpose – determine presence of life threats Open airway/perform spinal precautions Evaluate breathing Evaluate circulation Obtain AVPU and GCS scores Obtain general impression – Identify priority of transport

43 43 Region X Field Triage Criteria For Assessing Trauma Patients

44 44 Patient Transport Decision 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

45 45 Categorizing 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

46 46 Categorizing 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) » 0 - 4 points for respiratory rate » 0 - 4 points for systolic blood pressure

47 47 Categorizing 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

48 48 Patient Transport Decision 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

49 49 Categorizing 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

50 50 Category II Trauma Patient cont’d Mechanism of injury cont’d – 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

51 51 Category II Trauma Patient Co-morbid factors – Age < 5 without car/booster seat – Bleeding disorders or on anticoagulants – Pregnancy > 24 weeks

52 52 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

53 53 Communication Call early; update as needed – Hospital staff and resources may need to be mobilized The more critical the patient, most likely the shorter the report – Give important details – Paint the picture head to toe – Just as important is to give tasks not completed Intubation versus bagging IV access obtained or not

54 54 Abbreviated Radio Report Provide department name, vehicle number and receiving hospital 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

55 55 Fluid Challenges

56 56 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 98.6 0 body will cause core body temperature to decrease – Hypothermia results – Cold patients become acidotic patients

57 57 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

58 58 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 can be filled, but patient still in distress due to lack of oxygen carrying capacity (ie: blood) – Goal should not be to get a 120/80 blood pressure, rather to stabilize

59 59 Adult Fluid Challenges If your patient’s blood is becoming pink, 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!

60 60 Pediatric Fluid Challenges Pediatric shock protocol – EMS carries Normal Saline – Formula 20 ml per kg for fluid bolus – 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

61 61 Fluid Challenge Calculations 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

62 62 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

63 63 Case Study #1 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 @1002

64 64 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

65 65 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)

66 66 Case Study #1 Patient #1 – 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

67 67 Case Study #1 Respirations 22 with SPO 2 of 94% on room air – S P O 2 increased to 99% after oxygen @ 15 L via NRB ECG: Sinus tachycardia with rate of 110 Patient disoriented GCS = 9; RTS = 10

68 68 Case Study #1 Treatment plan: – Scene safety – Additional units requested, including FFL – ABC’s performed – Immobilization by c-collar, backboard & head immobilizers – Patient moved to ambulance – Patient exposed with multiple gunshot wounds discovered

69 69 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 Crew monitored lung sounds and femoral pulse throughout Patient transferred to FFL crew CMC (as Medical Control) notified

70 70 Case Study #1 Patient #2 – DOA from self inflicted gun shot wound – Was going through a divorce and called patient #1 to come pick up the kids – When Patient #1 arrived, Patient #2 asked her to step into the basement where he shot her multiple times and then turned gun on self – Children’s grandparents had also been called to pick up the kids

71 71 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

72 72 EZ IO Have you used one on a patient? High risk, low volume procedure – To retain competency need review and practice

73 73 EZ IO Indications – Must meet all indications Shock, arrest, or impending arrest Unconscious/unresponsive to verbal stimuli 2 unsuccessful IV attempts or 90 seconds duration

74 74 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

75 75 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)

76 76 Equipment Case Needle sizes used in Region X EZ connect tubing 10 ml syringe with saline

77 77 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

78 78 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

79 79 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

80 80

81 81 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 patient’s 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

82 82 Complete PI form for every use of the EZ IO needle Submit PI form to the EMS coordinator with the EMS run report EZ IO PI

83 83 Saline Lock/Extension Tubing 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

84 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 age – May use a saline lock cap on IV catheter hub for stable patients (not needing fluid resuscitation) 84 Region X SOP - Saline Lock

85 85 Note: – Saline lock is an older term Tends to mean a small cap device inserted into the proximal end of an IV catheter; no extra tubing – Equipment to be used Macrobore extension tubing with clave port – 5-7 inches of tubing with a male end to connect to the proximal IV catheter – Clave port on proximal end for connecting IV tubing or attaching a syringe Nowadays, if you say “saline lock” the macrobore and microbore tubing is the device the general hospital person would think you are discussing Terminology Saline Lock – Extension Tubing

86 86 “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

87 87 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

88 88 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

89 89 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

90 90 Improperly Secured IV Site Insertion site taped over Gauze bandaging under tape – Increased risk of infection IV site properly covered with see through dressing

91 91 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

92 92 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

93 93 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

94 94 Case Study #2 What questions do you have? – Has the patient been searched? The patient had not been searched A small pocket knife was retrieved by police Is there anything else to be done for assessment? – Check for multiple bullet wounds – Evaluate all sides of the patient A large wound was noted on the patient’s left back

95 95 Case Study #2 Interventions required – Immediately seal the open wounds Dressing secured on 3 sides – Provide high flow oxygen via non-rebreather – Establish IV access – Contact Medical Control What Category trauma is this patient? – Category I – penetration of torso

96 96 Case Study #2 - Documentation “Upon arrival found patient handcuffed. States, “they shot me” a few minutes ago. Bleeding is controlled. Patient states only mild pain especially with a deep breath. IV, O 2, monitor applied. Level I trauma center notified. Police informed of hospital destination.” What’s wrong with this documentation?

97 97 Case Study #2 No description of injuries noted – Size, location, presence/absence of bleeding – Lack of documentation of gun used when information is known No documentation of 3 sided dressing applied No documentation of response to treatment Interventions (ie: IV, O 2, monitor) do not need to be reduplicated in the comments No documentation of police in ambulance due to patient being handcuffed

98 98 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

99 99 Case Study #3 What actions are necessary for EMS to take for: – Scene safety? – Initial assessment? – Interventions? – Reassessment?

100 100 Case Study #3 Scene safety – Is the scene secured? – Where is the husband; who is with the husband? Initial assessment – 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 – AVPU – awake, cooperative, anxious

101 101 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

102 102 Case Study #3 Reassessment – 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

103 103 Case Study #3 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

104 104 Case Study #4 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 The bullet is visible in the wound What is first things first? – SAFETY, SAFETY, SAFETY

105 105 Case Study #4 Patient was in a local bar Was reported to be inebriated Was shot with a.25 ACP (relatively weak round; assailant is gone) Patient slumped to ground from bar stool Describe your care Score the GCS What report do you provide to the ED?

106 106 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

107 107 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

108 108 Case Study #4 Report – Description of wound(s) noted including body region – Include type of weapon used if information is available – Include 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)

109 109 Case Study #5 A patient presents as a walk-in to your department 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

110 110 Case Study #5 You can’t assess what you can’t see – remove clothing What injuries do you anticipate? – Heart, lung, vessels – Trachea – Esophagus Visible wound Object viewed on x-ray

111 111 Case Study #5 – Operative View Impaled object after removal Was near pulmonary artery but no damage Knife missed all vital structures

112 112 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 form the field Proper stabilization of the object to prevent further damage by movement Rapid OR for direct visualization and repair

113 113 HAVE A SAFE SHIFT! Thank you!

114 114 Bibliography Hoover, C. Fluid Resuscitation Controversies. EMS Magazine. March 2010. Proehl, J. Emergency Nursing Procedures, 4 th 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

115 115 Bibliography cont’d

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