1. Penetrating Trauma

2. Sections  Introduction to Penetrating Trauma  Physics of Penetrating Trauma  Specific Tissue/Organ Injuries  Special Concerns with Penetrating Trauma  Introduction to Penetrating Trauma  Physics of Penetrating Trauma  Specific Tissue/Organ Injuries  Special Concerns with Penetrating Trauma

3.  38,000 Deaths in US annually due to shootings.  Mechanisms of penetrating trauma  Knives, Arrows, Nails, etc  Understanding principles of energy exchange increase the Index of Suspicion associated with the MOI  38,000 Deaths in US annually due to shootings.  Mechanisms of penetrating trauma  Knives, Arrows, Nails, etc  Understanding principles of energy exchange increase the Index of Suspicion associated with the MOI Introduction to Penetrating Trauma

4.  Recall Kinetic Energy Equation  Greater the mass the greater the energy  Double mass = double KE  Greater the speed the greater the energy  Double speed = 4x increase KE  Recall Kinetic Energy Equation  Greater the mass the greater the energy  Double mass = double KE  Greater the speed the greater the energy  Double speed = 4x increase KE Physics of Penetrating Trauma (continued)

5. Physics of Penetrating Trauma  Small & Fast bullet can cause greater damage than large and slow.  Different bullets of different weights traveling at different speeds cause  Low Energy/Low Velocity Knives and arrows  Medium Energy/Medium Velocity Weapons Handguns, shotguns, low-powered rifles 250-400 mps  High Energy/High Velocity Assault Rifles 600-1,000 mps  Small & Fast bullet can cause greater damage than large and slow.  Different bullets of different weights traveling at different speeds cause  Low Energy/Low Velocity Knives and arrows  Medium Energy/Medium Velocity Weapons Handguns, shotguns, low-powered rifles 250-400 mps  High Energy/High Velocity Assault Rifles 600-1,000 mps (continued)

6. Physics of Penetrating Trauma  Bullet spins as it travels down barrel  Rifling in barrel  Allows bullet to travel straight with slight yaw  Bullet departs barrel, spinning with a slight wobble or yaw  Weapon forced backward and absorbs energy  Recoil  Bullet spins as it travels down barrel  Rifling in barrel  Allows bullet to travel straight with slight yaw  Bullet departs barrel, spinning with a slight wobble or yaw  Weapon forced backward and absorbs energy  Recoil (continued)

7. Physics of Penetrating Trauma  Remainder of energy propels bullet forward at a high rate of speed.  Trajectory is curved due to gravity  As bullet strikes object, it slows and energy is transferred to object.  Law of Conservation of Energy  Remainder of energy propels bullet forward at a high rate of speed.  Trajectory is curved due to gravity  As bullet strikes object, it slows and energy is transferred to object.  Law of Conservation of Energy

8. Ballistics  Study of the characteristics of projectiles in motion and effects upon objects impacted  Factors affecting energy exchange between a projectile and body tissue  Velocity  Profile  Stability  Expansion & Fragmentation  Secondary Impacts  Shape  Study of the characteristics of projectiles in motion and effects upon objects impacted  Factors affecting energy exchange between a projectile and body tissue  Velocity  Profile  Stability  Expansion & Fragmentation  Secondary Impacts  Shape

9. Energy Dissipation  Drag:  wind resistance  Cavitation:  formation of a partial vacuum and cavity within a semi-fluid medium  Profile:  Size and shape of a projectile as it contacts a target  Larger the profile=greater energy exchange  Expansion and fragmentation results in damage  Stability  Allows for straighter trajectory  Decreases after striking object results in tumbling  Drag:  wind resistance  Cavitation:  formation of a partial vacuum and cavity within a semi-fluid medium  Profile:  Size and shape of a projectile as it contacts a target  Larger the profile=greater energy exchange  Expansion and fragmentation results in damage  Stability  Allows for straighter trajectory  Decreases after striking object results in tumbling

12. Aspects of Ballistics  Velocity  Causes Trajectory  Faster = straighter trajectory  Slower = more curved due to gravity  Velocity  Causes Trajectory  Faster = straighter trajectory  Slower = more curved due to gravity

13. Aspects of Ballistics  Profile  Portion of bullet you see as it travels towards you  Larger profile = greater energy exchange  Caliber  Diameter of a bullet (ID of gun) 0.22 caliber = 0.22 inches  Bullets become unstable as they pass from one medium to another.  Profile  Portion of bullet you see as it travels towards you  Larger profile = greater energy exchange  Caliber  Diameter of a bullet (ID of gun) 0.22 caliber = 0.22 inches  Bullets become unstable as they pass from one medium to another.

14. Aspects of Ballistics  Stability  Bullet length increases bullet tumbling  Can reduce the accuracy of the shot  Reduced by Rifling in barrel (spinning)  Yaw  Gyroscopic effect on the center axis of the bullet that reduces tumbling  Tumbling of bullet once it strikes object  Reduces kinetic energy  Greater tissue damage  Stability  Bullet length increases bullet tumbling  Can reduce the accuracy of the shot  Reduced by Rifling in barrel (spinning)  Yaw  Gyroscopic effect on the center axis of the bullet that reduces tumbling  Tumbling of bullet once it strikes object  Reduces kinetic energy  Greater tissue damage

15. Bullet Gyroscopic Effect

16. Aspects of Ballistics  Expansion & Fragmentation  Results in increased profile  Mushrooming  Initial impact forces may result in fragmenting  Greater tissue damage  Expansion & Fragmentation  Results in increased profile  Mushrooming  Initial impact forces may result in fragmenting  Greater tissue damage

17. Aspects of Ballistics  Secondary Impacts  Bullet striking other objects can cause yaw and tumble  Body Armor (Kevlar)  Transmits energy throughout entire vest resulting in blunt trauma Myocardial Contusion Pulmonary Contusion Rib Fractures  Shape  Handgun Ammunition = Blunt = Tumble  Rifle Ammunition = Pointed = Piercing  Secondary Impacts  Bullet striking other objects can cause yaw and tumble  Body Armor (Kevlar)  Transmits energy throughout entire vest resulting in blunt trauma Myocardial Contusion Pulmonary Contusion Rib Fractures  Shape  Handgun Ammunition = Blunt = Tumble  Rifle Ammunition = Pointed = Piercing

18.  Handguns  Small caliber, short barrel, medium-velocity  Effective at close range  Severity of injury based upon organs damaged  Rifle  High-velocity, longer barrel, large caliber  Increased accuracy at far distances  Assault Rifles  Large magazine, semi- or full-automatic  Similar injury to hunting rifles  Multiple wounds  Handguns  Small caliber, short barrel, medium-velocity  Effective at close range  Severity of injury based upon organs damaged  Rifle  High-velocity, longer barrel, large caliber  Increased accuracy at far distances  Assault Rifles  Large magazine, semi- or full-automatic  Similar injury to hunting rifles  Multiple wounds Specific Weapon Characteristics

19.  Shotgun  Slug or pellets at medium velocity  00 (1/3”) to #9 (pin head sized)  Larger the load, the smaller the number of projectiles  Deadly at close range  Knives & Arrows  Low-energy & low-velocity  Damage related to depth and angle of attack  Movement of the victim can increase damage  Shotgun  Slug or pellets at medium velocity  00 (1/3”) to #9 (pin head sized)  Larger the load, the smaller the number of projectiles  Deadly at close range  Knives & Arrows  Low-energy & low-velocity  Damage related to depth and angle of attack  Movement of the victim can increase damage Specific Weapon Characteristics

20. Damage Pathway  Projectile Injury Process  Tip impacts tissue  Tissue pushed forward and to the side  Tissue collides with adjacent tissue  Shock wave of pressure forward and lateral Moves perpendicular to bullet path  Rapid compression, crushes and tears tissue  Cavity forms behind bullet pulling in debris with suction.  Projectile Injury Process  Tip impacts tissue  Tissue pushed forward and to the side  Tissue collides with adjacent tissue  Shock wave of pressure forward and lateral Moves perpendicular to bullet path  Rapid compression, crushes and tears tissue  Cavity forms behind bullet pulling in debris with suction.

21. Damage Pathway  Direct Injury  Damage done as the projectile strikes tissue  Pressure Shock Wave  Human tissue is semi-fluid  Solid and dense organs are damaged greatly  Temporary Cavity  Due to cavitation  Permanent Cavity  Due to seriously damaged tissue  Zone of Injury  Area that extends beyond the area of permanent injury  Direct Injury  Damage done as the projectile strikes tissue  Pressure Shock Wave  Human tissue is semi-fluid  Solid and dense organs are damaged greatly  Temporary Cavity  Due to cavitation  Permanent Cavity  Due to seriously damaged tissue  Zone of Injury  Area that extends beyond the area of permanent injury

22. Ballistics Cavitation

23. Low-Velocity Wounds  Objects  Knives, Ice-picks, Arrows  Flying objects or debris  Injury limited to tissue impacted  Object pathway  Object twisting or moved  Oblique angle  Attacker Characteristics  Males: outward and crosswise  Females: overhand and downward  Objects  Knives, Ice-picks, Arrows  Flying objects or debris  Injury limited to tissue impacted  Object pathway  Object twisting or moved  Oblique angle  Attacker Characteristics  Males: outward and crosswise  Females: overhand and downward

24.  Density of tissue affects the efficiency of energy transmission  Resiliency  Strength and elasticity of an object  Connective Tissue  Absorbs energy and limits tissue damage  Organs  Solid Organs  Dense and low resilience  Hollow Organs  Fluid filled: transmit energy = increased damage  Air filled: absorbs energy = less damage  Density of tissue affects the efficiency of energy transmission  Resiliency  Strength and elasticity of an object  Connective Tissue  Absorbs energy and limits tissue damage  Organs  Solid Organs  Dense and low resilience  Hollow Organs  Fluid filled: transmit energy = increased damage  Air filled: absorbs energy = less damage Specific Tissue & Organ Injuries

25.  Lungs  Air in lung absorbs energy  Parenchyma is compressed and rebounds  Pneumothorax or hemothorax can result  Bone  Resists displacement until it shatters  Alters projectile path  Lungs  Air in lung absorbs energy  Parenchyma is compressed and rebounds  Pneumothorax or hemothorax can result  Bone  Resists displacement until it shatters  Alters projectile path Specific Tissue & Organ Injuries

26. General Body Regions  Extremities  Injury limited to resiliency of tissue  60-80% of injuries with <10% mortality  Abdomen (Includes Pelvis)  Highly susceptible to injury and hemorrhage  Bowel perforation: 12-24 hrs peritoneal irritation  Thorax  Rib impact results in explosive energy  Heart & great vessels have extensive damage due to lack of fluid compression  Any large chest wound compromises breathing  Extremities  Injury limited to resiliency of tissue  60-80% of injuries with <10% mortality  Abdomen (Includes Pelvis)  Highly susceptible to injury and hemorrhage  Bowel perforation: 12-24 hrs peritoneal irritation  Thorax  Rib impact results in explosive energy  Heart & great vessels have extensive damage due to lack of fluid compression  Any large chest wound compromises breathing

27. General Body Regions  Neck  Damages Trachea and Blood Vessels  Neurological problems  Sucking neck wound  Head  Cavitational energy trapped inside skull  Serious bleeding and lethal  Neck  Damages Trachea and Blood Vessels  Neurological problems  Sucking neck wound  Head  Cavitational energy trapped inside skull  Serious bleeding and lethal

28. Wound Characteristics  Entrance Wounds  Size of bullet profile for non-deforming bullets  Deforming projectiles may cause large wounds  Close Range  Powder Burns (Tattooing of powder)  1-2 mm circle of discoloration  Localized subcutaneous emphysema  Exit Wounds  Appears to be “Blown” outward  Pressure wave  Entrance Wounds  Size of bullet profile for non-deforming bullets  Deforming projectiles may cause large wounds  Close Range  Powder Burns (Tattooing of powder)  1-2 mm circle of discoloration  Localized subcutaneous emphysema  Exit Wounds  Appears to be “Blown” outward  Pressure wave

29.  Scene Size-Up  Law-Enforcement  DO NOT ENTER UNTIL SCENE IS SAFE!  Weapons: Victim or Assailant  Assailants  IF A CRIME SCENE  DOCUMENT  DO NOT DISTURB EVIDENCE  RETAIN CLOTHING, ETC  LIMIT PERSONNEL INVOLVEMENT  Scene Size-Up  Law-Enforcement  DO NOT ENTER UNTIL SCENE IS SAFE!  Weapons: Victim or Assailant  Assailants  IF A CRIME SCENE  DOCUMENT  DO NOT DISTURB EVIDENCE  RETAIN CLOTHING, ETC  LIMIT PERSONNEL INVOLVEMENT Special Concerns with Penetrating Trauma

30.  Penetrating Wound Assessment  Internal Organ Injury Potential  Entrance & Exit Wounds  Penetrating Wound Assessment  Internal Organ Injury Potential  Entrance & Exit Wounds Special Concerns with Penetrating Trauma PROVIDE RAPID TRANSPORT FOR ANY GSW TO HEAD, CHEST, OR ABDOMEN. TREAT AGGRESIVELY FOR SHOCK!!

31.  Penetrating Wound Care  Facial Wounds  Difficult intubations Depress chest Pass ET through bubbling tissue Consider LMA and Combitube Consider Cricothyreotomy & Cricothyreostomy  Chest Wounds  Pneumothorax  2/3” the diameter of the trachea or larger to entrain air  3-sided occlusive dressing  Needle Decompress  Pericardial Tamponade  Penetrating Wound Care  Facial Wounds  Difficult intubations Depress chest Pass ET through bubbling tissue Consider LMA and Combitube Consider Cricothyreotomy & Cricothyreostomy  Chest Wounds  Pneumothorax  2/3” the diameter of the trachea or larger to entrain air  3-sided occlusive dressing  Needle Decompress  Pericardial Tamponade Special Concerns with Penetrating Trauma

32.  Impaled Objects  Low-energy  Dangerous to remove  DO NOT REMOVE  UNLESS In Cheek Interferes with CPR: ASSESS!!!  Impaled Objects  Low-energy  Dangerous to remove  DO NOT REMOVE  UNLESS In Cheek Interferes with CPR: ASSESS!!! Special Concerns with Penetrating Trauma