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2/6/2013
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PenetratingTrauma
Pre-hospital Care
Scott C. EdminsterMD, FACEP
Medical Director
City of Spokane
Fire Department
Unique crowd
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Trauma is by far the leading cause of death in young people
AgeInYrs.
Significant Mechanism of Injury?
Penetrating injury of head, chest, or abdomen
Type of weapon (small vs large cal’)
Low energy or high energy? (blast?)
Assessing the Trauma Patient
Is there a significant mechanism of injury?
YesPerform a rapid
assessment.
NoPerform a focused
assessment.
Rapid TraumaAssessment
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ABCs not
• Airway
• Breathing
• Circulation
• Disability
Immediate Actionsto be completed while assessing
• O2
• IV (preferably 2 & large)
• Monitor
E = MC2
GCS < 8 = intubate
(Obstructive)
Quick Assessment Of
Shock in Trauma
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GSW, High Velocity Exit
GSW Head, entrance or exit?
Don’t Miss the Serious
Because of the Obvious
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Inspect and Palpate forDCAP-BTLS
DCAP
====
DeformitiesContusionsAbrasionsPunctures/Penetrations
====
BTLS
BurnsTendernessLacerationsSwelling
Tenderness
Punctures/Penetrations
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Brief Neuro Exam
• Mental Status• Pupils• Motor function
X 4• Sensory
function X 4 + trunk
Primary Survey is Compelling(unstable or potentially unstable)
• Address compelling issues to your level of training
• Call for ALS
• Transport (scoop and run)
• IVs and Tubes can be placed en-route
If No Significant Mechanismof Injury
Reconsider mechanism of injury.
Determine chief complaint.
Perform focused physical exam based on:
Chief complaint
Mechanism of injury
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CASES
Is this chest or abdominal trauma?
The patient is a victim of two stab wounds to the torso. One wound is along the left sixth intercostal space and one is in the right lower quadrant of the abdomen.
How could penetrating trauma to the lower thorax involve the abdomen?
You respond to a call and find a 16-year-old male who has been shot in the right upper chest. Police inform you that the weapon was a .22-caliber handgun.
What do you know about .22-caliber bullets?
Primary SurveyA - Patent
B - VR fast, BS diminished on right; no exit
wound noted; air not bubbling through
wound
C - No external bleeding, fast pulse rate
D - GCS score 15
What injuries do you suspect?
How would you manage this patient?
What is missing on this exam?
Pathophysiology of Open Pneumothorax Pathophysiology of Tension Pneumo’
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Simple Pneumothorax• Mechanism of injury
• Ventilation
– Decreased or absent BS
– Mild respiratory distress
• Treatment
– Oxygen
– Monitor
– Rapid transport
Tension Pneumothorax• Mechanism of injury
• Ventilation
– Decreased or absent BS
– More severe respiratory distress
• Hemodynamic compromise
• Treatment
– Oxygen
– Needle decompression
– Rapid transport
Manifestations of Tension Pneumothorax
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An intoxicated 50-year-old male is found with a self-inflicted injury to his left chest. A steak knife is impaled in the left third intercostal space on the midclavicular line.
Primary Survey
A - PatentB - VR rapid; normal BS bilaterallyC - No external bleeding, fast pulse rate, no
palpable radial pulse, muffled heart tonesD - GCS score 14 (E-4, V-4, M-6)E - JVD noted
What do these findings suggest?What is your management?
Opens eyes spontaneouslyConfused speechObeys
Same patient’s CXR in ED
If you can’t do a thoracotomyand strip the pericardium…
and, you aren’t allowed by your protocols to dopericardiocentesis…..
What can you do?
FILLING PRESSURE
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Pathophysiology
Peritoneal cavity:
• Solid organs (liver, spleen) hemorrhage
• Hollow organs (small intestine, colon) filled with enzymes and bacteria peritonitis/ bleeding
• Can hold large volume of blood
Pathophysiology
Retroperitoneal cavity:
• Solid organs (kidneys, pancreas)
• Large blood vessels (aorta and vena cava)
• Potential space that can hold massive amount of blood
Spleen
Pancreas
Bowell loops
A 28-year-old male has been shot in the neck by his girlfriend.
Primary Survey
A - Patent
B - Fast, BS equal
C - Copious external hemorrhage from neck wound,
radial pulse fast and weak
D - GCS score 15, no neurologic deficits in extremities
E - Expanding hematoma to left side of neck
When is spinal immobilization indicated for penetrating trauma?
Who gets cervical immobilization?
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• Unstable spinal fractures from penetrating trauma are extremely rare
• Life-threatening conditions take priority
Penetrating trauma
Neurological deficit/complaint?
NoYes
IMMOBILIZE IMMOBILIZATION NOT INDICATED
Rapid transportRapid transport
When in doubt ?????????
Your patient sustained a close-range shotgun blast to the abdomen. A segment of bowel is
eviscerated.
How are eviscerations managed?
Impaled Objects
How are impaled objects managed in the field?
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Direct Pressure Proximal Pressure Points
Body Substance Isolation/universal precautions
Mechanical Advantage Tourniquet
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To summarize• Give them O2/ventilate if they need it.• Stop or slow external bleeding.• Give them Fluids vigorously.• Recognize Tension Pneumo’ & treat it.• Protect the spinal cord.• Get them to the right place.• Do it all quickly!
STEP 3; medical control makes destination decisionState of WA Trauma Triage Tool, Cont’d
if step 1 or 2 criterion met Trauma Triage
When in doubt… try to err on the side of taking the patient to the highest level of care!
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“If You Didn’t Document It,You Didn’t Do It!”
Test Questions1. What is the leading killer of young people in the
United States?A. Cancer C. Heart diseaseB. Infectious diseases D. Trauma
2. What is the quickest way to ascertain shock in a trauma patient?A. Look at the feetB. Check the BP with a cuffC. Check for pulses in the groin, neck and armD. Look at the neck veins
3. The pictured trauma patient is in shock.
What is the best way to ascertain whether the shock is hemorrhagic or cardiogenic (tension pneumo’, cardiac contusion or tamponade)?A. Look at the feetB. Check the BP with a cuffC. Check for pulses in the groin, neck and armD. Look at the neck veins
4. Which is not true regarding spinal immobilization in penetrating trauma patients?A. Unstable spinal fractures from penetrating
trauma are extremely rare.B. When in doubt err on the side of immobilization
and spinal precautions.C. If there are no neurologic deficits or complaints
cervical spine immobilization is not necessary.D. Mechanism of injury is not a decisive factor.
5. True or False – Penetrating objects should be removed in the field and protruding organs should be gently put back in place before long transports.
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Happy 100th!
If you have a scenario or case study idea for our 100th presentation in March, please email to Jackie Williams, [email protected]. It should be brief so we can share as many as possible.
Wade Scoles and Dr. Jim Nania will be responding to your ideas.
Send no later than Friday, February 22nd.
Questions?
Contact: Carolyn Stovall509-242-4264
[email protected]: 509-232-8344
Special thanks to
Sheila Crow
Stitchin’ Dreams Embroidery
For providing our Secret Question prize
Updates Please
If the name and address of your agency contact has changed, please let us know. This is where
we mail your certificates.
Email updated name, address and email to:
Jackie Williams – [email protected]
