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Penetrating Trauma

ECRN Mod II 2010 CECondell Medical Center EMS System

IDPH Site code #107200E-1210

Prepared by: Lt. William Hoover, Medical OfficerWauconda Fire District

Reviewed/revised by: Sharon Hopkins, RN, BSN, EMT-P

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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

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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

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Objectives cont’d

• 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

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Gunshots…

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Gunshot Victims

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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

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Perforating Gunshots

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Penetrating gunshot

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Entrance wound

• Surrounded by a reddish-brown area of abraded skin, known as the abrasion ring

• Small amounts of blood

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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

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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

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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

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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

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Types of Firearms

• Pistols– Revolver– Semi-Automatic

• Shotguns– Pump– Semi-Automatic

• Rifles– Bolt– Lever action

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Pistols – Medium Velocity

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Shotguns – Medium Velocity

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Rifles – High Velocity

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Projectiles – High Velocity

• Rifle bullets are designed to have much greater velocity than shotgun bullets

• Different size of casing provides more or less gunpowder

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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

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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

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Shotgun Shell – Medium Velocity

12 Gauge Shotgun Slug 12 Gauge Shotgun with #6 shot

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.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

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Compound Bows and Arrows – Medium Velocity

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Arrowhead Types – Medium Velocity

Target tips Broadhead

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Arrow injuries

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Another ouch….

• How would you initially stabilize these wounds?

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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

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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

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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

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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

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Police Officer StabbingWhat injuries do you suspect?

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Organ Injury

Patient was shotwith a MAC-10

machine gun and sustained aliver injury

Lap sponge under fold of skin

Liver surface with injury noted to organ

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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)

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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

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Field Management Goals

Focus on the basics

If there is a hole – plug itIf there is bleeding – stop it

If they can’t breathe – ventilate

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Region X

Field Triage Criteria For Assessing Trauma Patients

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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

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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

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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

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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 <10 or >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

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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

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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

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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

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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

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Category II Trauma Patient

• Co-morbid factors– Age < 5 without car/booster seat– Bleeding disorders or on anticoagulants– Pregnancy > 24 weeks

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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

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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

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Abbreviated Radio ReportDepartment name, vehicle number and receiving

hospitalEMS to state, “this is an abbreviated report”

Provide nature of situation and SOP being followed

Age and sex of patientChief complaint and brief historyAirway and vascular statusCurrent vital signs, GCSMajor interventions completed or being

attemptedETA

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Fluid Challenges

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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 98.60 body will cause core body

temperature to decrease– Hypothermia results– Cold patients become acidotic patients

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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

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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

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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 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!

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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

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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

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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

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Case Study #1

• EMS 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 made @1002

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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

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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)

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Case Study #1

• Patient #1 cont’d– 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

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Case Study #1

• Respirations 22 with SPO2 of 94% on room air – SPO2 increased to 99% after oxygen @ 15 L via NRB

• ECG: Sinus tachycardia with rate of 110• Patient disoriented• GCS = 9; RTS = 10

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Case Study #1

• Treatment plan:– Scene safety (field and in ED)– ABC’s performed– Rapid transport with early communication to receiving

facility– Supplemental O2, IV enroute, monitor

– Immobilization by c-collar, backboard & head immobilizers

– Patient needs to be exposed for evaluation of multiple gunshot wounds

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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

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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

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EZ IO

• Have you used one on a patient or cared for a patient with one?

• High risk, low volume procedure

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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

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EZ IO• Contraindications

– Fracture of the tibia or femur– Infection at insertion site– Previous 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

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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)

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Equipment Case

Needle sizes used in Region X

EZ connect tubing

10 ml syringe with saline

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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 900 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

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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

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

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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

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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

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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

• 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)

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Region X SOP - Saline Lock

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“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

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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

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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

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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

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Improperly Secured IV Site

• Insertion site taped over• Gauze bandaging under tape

– Increased risk of infection

IV site properly covered with see through dressing

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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.

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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

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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

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

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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

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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; SpO2 98%; warm & dry• No active bleeding

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Case Study #3

• What injuries do you anticipate knowing entry point and angle of impalement?

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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

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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

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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

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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

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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

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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

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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

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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, O2, monitor)

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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

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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

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Case Study #5 – Operative View

• Impaled object after removal• Was near pulmonary artery but no damage• Knife missed all vital structures

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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

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Bibliography• Hoover, C. Fluid Resuscitation Controversies. EMS

Magazine. March 2010.• Proehl, J. Emergency Nursing Procedures, 4th 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• Olliver.family.gen.nz/launchpad/Head_wound.png• www.cabelas.com<http://www.cabelas.com>• www.jems.com<http://www.jems.com>

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Bibliography cont’d

• www.remington.com<http://www.remington.com>• www.vidacare.com• www.Wikipedia.org<http://www.Wikipedia.org>• www.winchester.com<http://www.winchester. com>