1. CASE STUDIES AND SPECIAL SKILLS
TRAUMA

2. CASE STUDY #7
22-YEAR-OLD MALE WITH A GUN SHOT WOUND TO THE CHEST

3. At 10:50 am, your unit is dispatched to a convenience store in response to a shooting. The shooting occurred during a robbery attempt in which the clerk shot the perpetrator. Law enforcement is at the scene and notifies you by radio that the scene is secure You arrive at the scene at 10:57 am where you find the patient, a 22-year-old male who is semi conscious and in obvious respiratory distress. The patient is being cared for by fist responders. They have already sealed a small caliber gunshot wound to the left side of his chest and placed him on 100% supplemental oxygen via a nonrebreathing mask.

4. 1. Why is it important to immediately seal an open wound to the thoracic cavity?
Because of the mechanism of injury(gunshot wound to the chest) and the patient’s obvious respiratory distress, you should suspect an open pneumothorax(sucking chest wound)
An open pneumothorax develops when the pleural space is directly exposed to atmospheric pressure.
Immediate sealing of the wound with an occlusive dressing will prevent air from entering the pleural space, thus facilitating the entry of air into the lungs.

5. INITIAL ASSESSMENT Mechanism of injury Gunshot wound to the chest
Level of Consciousness
Responsive to painful stimuli only
Chief Complaint
Decreased level of consciousness, respiratory distress
Airway and Breathing
Airway is patent, respirations are rapid, labored and shallow
Circulation
Radial pulses are weakly present and rapid; skin is cool, clammy and pale; bleeding from the chest wall has been controlled; no other bleeding present

6. Because of the patient’s decreased mental status and poor respiratory effort, your partner inserts a nasopharyngeal airway and with the help of one of the first responders, initiates positive-pressure ventilatory assistance with a BVM device and 100% oxygen.

7. RAPID TRAUMA ASSESSMENT:
Head
No obvious trauma
Neck
Trachea is midline; jugular veins appear normal; no cervical spine deformities
Chest
Open wound to the upper-left anterior chest(sealed); chest wall movement is asymmetrical; breath sounds are diminished over the upper-left anterior chest.
Abdomen/Pelvis
Abdomen is soft and nontender; pelvis is stable
Lower extremities
No obvious trauma; perfusion and sensory/motor functions are grossly intact
Upper extremities
Posterior

8. After applying a cervical collar and fully immobilizing the patient with a long spine board, you quickly load him into the ambulance, while your partner obtains the baseline vital signs and a SAMPLE history, you apply the ECG leads and assess the patient’s cardiac rhythm

9. BASELINE VITAL SIGNS AND SAMPLE HISTORY:
Blood Pressure
70/40 mm Hg
Pulse
128 beats/min, weak and regular
Respiration
28 breaths/min and shallow(ventilated with 100% oxygen)
Oxygen Saturation
89% (ventilated with 100% oxygen)
Signs and symptoms
Open chest wound(sealed), signs of shock, inadequate breathing
Allergies
unknown
Medications
Pertinent past history
Last oral intake
Events leading to present illness
According to the clerk, “He tried to rob me, so I shot him with my .22 caliber pistol that I keep behind the counter”

10. Because of the profound hypotension and decreasing oxygen saturation, you reauscultate the patient’s breath sounds and note that they are absent on the entire left side.
Additionally you note that his jugular veins appear somewhat distended, his trachea has deviated to the right side, and his respirations have become increasingly labored

11. 2. Why is this patient’s condition deteriorating
2. Why is this patient’s condition deteriorating? What corrective action must you take?
The patient is likely developing tension pneumothorax, as evident by:
1. absent breath sounds on the same side of the injury
2. hypotension
3. jugular venous distension
4. increased respiratory difficulty
5. asymmetrical chest wall movement
6. tracheal deviation
Immediate corrective action is to lift one side of the occlusive dressing to allow air to escape from the pleural space. If this remains unsuccessful, a needle thoracentesis will have to be performed.

12. You take immediate steps to correct the problem that is causing the patient’s deterioration. You note improvement in the patient’s respiratory effort. His mental status has also improved.
You apply 100% oxygen via a nonrebreathing mask and secure one large-bore IV line of saline, and perform a detailed physical examination.

13. DETAILED PHYSICAL EXAMINATION
Head and face
No obvious trauma to head or face, mouth and nose are clear, pupils equal and reactive to light
Neck
Trachea has now returned to the midline; jugular veins are less distended
Chest
Chest wound is sealed; breath sounds are diminished in the upper-left anterior chest, and chest wall movement is slightly asymmetrical
Abdomen/pelvis
Abdomen is soft and non-tender; pelvis is stable
Lower extremities
No obvious trauma; pedal pulses weakly present; sensory and motor functions grossly intact
Upper extremities
No obvious trauma; radial pulses weakly present; sensory and motor functions grossly intact
Posterior
Examined in the rapid trauma assessment, patient is immobilized by long sine board

14. The patient’s condition remains stable
The patient’s condition remains stable. He is conscious and alert to person, and place but cannot remember what happened. After performing an ongoing assessment, you call your report to the emergency dept.

15. ONGOING ASSESSMENT Level of consciousness
Conscious and alert to persona and place, cannot remember preceding events
Airway and breathing
Airway remains patent; respirations 22 breaths/min and slightly labored
Oxygen saturation
96%(on 100% oxygen)
Breath sounds
Slightly diminished in upper-left anterior chest
Jugular veins
Non-distended
Blood pressure
118/66 mm Hg
pulse
94 beats/min, strong and regular
ECG
Normal sinus rhythm

16. 3. Describe the pathophysiology and emergency care of a tension pneumothorax
A tension pneumothorax is a life-threatening emergency that develops when air within the thoracic cavity cannot exit the pleural space. The result is severe respiratory distress, shock(hypoperfusion) and death if not treated immediately
A tension pneumothorax can also develop following placement of an occlusive dressing over a sucking chest wound(open pneumothorax)

17. Emergency care for a tension pneumothorax:
1. Ensure a patent airway
2. Provide 100% supplemental oxygen/ventilatory support as needed
3. Perform a needle thoracentesis to evacuate air from the pleural space.
4. If internal hemorrhage is suspected, maintain IV line and infuse fluids to maintain adequate perfusion.
5. Fully immobilize the patient’s spine if the MOI suggests spinal trauma
6. Promptly transport the patient to a trauma center .

18. THANK YOU