Gunshot wounds Warning: This presentation has extremely graphic pictures! Richard P. Kness, EMT- P Objectives After this lesson the student will be able to: List scene safety issues Describe procedures to protect crime scene evidence recognize signs and symptoms of a gunshot wound categorize treatment for gunshot wounds based on location and travel of bullet Document scene and care provided Gunshot Wounds Injuries created by medium or highvelocity weapons Scene Size-Up Overall Assessment Scheme Scene Size-Up Initial Assessment Trauma Physical Exam Vital Signs & SAMPLE History HOSP Detailed Physical Exam Ongoing Assessment Scene Size-Up Determining any threats to your own safety or to the safety of your patients or bystanders, to determine the nature of the call, and to decide if you will need additional help Scene Safety Scene Safety Protect bystanders (prevent them from becoming patients). Never enter an unsafe scene. Make scene safe or call for someone who can. The “Danger zone” may be far reaching when a gun is involved Scene Violence Use scene clues: Fighting Loud voices Alcohol/drug use Unusual silence Prior experience Crime Scenes and Violence Every Gun shot wound is considered a crime scene until investigated by Law Enforcement Crime Scenes and Violence Work with Law Enforcement: (Don’t be a “mobile evidence destruction unit”) If possible do not disturb evidence: Weapons Clothing damaged doors, or windows where entrance was made Blood pools or tracked blood Other considerations? Body Substance Isolation Body Substance Isolation Anticipate the need for BSI. Always have BSI equipment available. Use appropriate equipment to prevent exposure. Gloves Face and eye protection Gown Assessment of the Trauma Patient Overall Assessment Scheme Scene Size-Up Initial Assessment Trauma Physical Exam Vital Signs & SAMPLE History HOSP Detailed Physical Exam Ongoing Assessment Assessing the Trauma Patient Is there a significant mechanism of injury? Yes No Perform a rapid assessment. Perform a focused assessment. Mechanism of Injury Mechanism of Injury Gunshot wounds Mechanism of Injury The physical event that caused an injury (knife wound, gun shot wound, motor vehicle accident, etc.) Mechanism of Injury: Penetrating Trauma Velocity Low velocity–knife Medium velocity–handgun, shotgun (generally less than 2,000 feet-per-minute) High velocity–rifle (generally greater than 2,000 feet-per-minute) Body region penetrated Exit wounds Wound ballistics (Kinematics) Wound Ballistics: Medium and High velocity wounds Factors that contribute to tissue damage include: Bullet size: The larger the bullet, the more resistance and the larger the permanent tract Bullet deformity: Hollow point and soft nose flatten out on impact, resulting in a larger surface area involved. Wound Ballistics: Medium and High velocity wounds tissue damage continued: Semijacket: The jacket expands and adds to the surface area Tumbling: Tumbling of the bullet causes a wider path of destruction Yaw: The bullet can oscillate vertically and horizontally (wobble) about its axis, resulting in a larger surface area presenting to the tissue. Gunshot Wounds: Cavitation To what is cavitation (shock wave) related? Gunshot Wounds Entrance and exit wounds Wound Ballistics: Medium and High velocity wounds The wound consists of three parts: Entry wound: Usually smaller than the exit wound Exit wound: Not all gunshot wounds will have exit wounds and on occasion there be multiple exit wounds due to fragmentation of bone or the bullet. Generally the exit wound is larger and has ragged edges. Entrance and Exit Wounds Wound Ballistics: Medium and High velocity wounds The wound consists of three parts: Internal wound: Medium-velocity bullets inflict damage primarily by damaging tissue that the bullet contacts; Highvelocity bullets inflict damage by tissue contact and transfer of kinetic energy (the shock wave producing a temporary cavity) to surrounding tissues Mechanism of Injury: Penetrating Trauma Gunshot wound trauma injuries Penetrating Trauma Injuries Head: The skull is a closed space, thus presenting some unique situations: The shock wave has no place to go therefore the brain tissue can be compressed. If the forces are strong enough the skull may explode from the inside out. A medium velocity bullet may follow the curvature of the interior of the skull. This path can produce significant damage Punctures/Penetrations (Gunshot wounds) Punctures/Penetrations (Gunshot wounds) Penetrating Trauma Injuries Thorax: Three major groups of structures inside the thoracic cavity must be considered in evaluating a penetrating injury to the chest: Lungs: Less dense tissue so injuries are generally from the bullet tract and less so from a shock wave. Serious injuries include a pneumothroax or hemothorax Penetrating Trauma Injuries Thorax: Vasular: Blood and muscle is more dense than lung tissue, therefore it is more susceptible to shock waves in addition to the bullet track. Injuries include damage to the aorta and the superior vena cava as well as injury to the heart muscle. Penetrating Trauma Injuries Thorax: Gastrointestinal: The esophagus is located in the thorax and may be injured by the bullet track Injuries include damage to the esophagus as well as spilling any contents into the thoracic cavity which can lead to infection. Punctures/Penetrations (Gunshot wounds) Penetrating Trauma Injuries Abdomen: The abdomen contains structures of three types: Air filled, solid and bony. Gastrointestinal: The majority of the GI system is located in the abdomen. Most of the GI tract structures are considered to be air filled. Injuries include damage to the GI system structures as well as spilling any contents into the abdominal cavity which can lead to infection. Penetrating Trauma Injuries Abdomen: Solid organs: The solid organ of the abdomen are very susceptible to direct injury as well as injury from the shock wave. Injuries include direct and shock wave damage to all of the solid organs such as the liver, spleen, pancreas, and the kidneys in the retroperitoneal space. Let’s not forget about the bladder, uterus, ovaries, gall bladder, and major blood vessels such as the vena cava and the aorta. Penetrating Trauma Injuries Abdomen: Bones: The pelvis is a very vascular organ. Fracture of the pelvic due to a gunshot wound can lead to major blood loss Injuries are generally limited to direct bullet track damage. The bone fragments may become secondary missiles and cause additional damage. Shotgun Wounds The ultimate in fragmentation is created by shotgun wounds Penetrating Trauma Injuries Muscles, peripheral nerves and blood vessels, connective tissue, skin and bones: All of these tissues may suffer direct injury or shock wave injuries. Injuries may include: tissue loss, bleeding, and loss of function, Open Wound Rapid Trauma Assessment Rapid Trauma Assessment Head Neck Chest Abdomen Pelvis Extremities Posterior Inspect and Palpate for DCAP-BTLS D C A P = = = = Deformities Contusions Abrasions Punctures/ Penetrations B T L S = = = = Burns Tenderness Lacerations Swelling Significant Mechanism of Injury Assess baseline vital signs. Obtain SAMPLE history. Consider requesting ALS. Reconsider transport decision. SAMPLE History S = Signs and symptoms A = Allergies M = Medications P L = Pertinent past history = Last oral intake E = Events leading to injury or illness If No Significant Mechanism of Injury Reconsider mechanism of injury. Determine chief complaint. Perform focused physical exam based on: Chief complaint Mechanism of injury Detailed Physical Exam Who Needs a Detailed Physical Exam? Determined by patient’s condition: After critical interventions for a patient with significant MOI Occasionally for a patient with no significant MOI Rarely for a medical patient Who Needs a Detailed Physical Exam? You may never have time to perform a detailed exam on a patient with critical injuries. Steps in the Detailed Physical Exam The Detailed Physical Exam Head Neck Chest Assess areas examined in rapid trauma assessment plus: Abdomen Face Pelvis Ears Extremities Eyes Posterior Nose Mouth The Detailed Physical Exam Examine slower than during rapid trauma assessment. Often done during transport. Reassess vital signs. Bleeding and Shock External Bleeding Severity of Blood Loss Determined by: General impression of blood loss Signs or symptoms of hypoperfusion Sudden loss of... One liter of blood in an adult Half a liter of blood in a child 100-200cc of blood in an infant ...is serious! Blood Loss Uncontrolled bleeding or significant blood loss leads to shock (hypoperfusion) and possibly death! Do not wait for signs and symptoms to appear before beginning treatment! Internal Bleeding Signs & Symptoms of Internal Bleeding Significant MOI Pain, tenderness, deformity, swelling, discoloration Bleeding from the mouth, rectum, or vagina Tender, rigid, or distended abdomen Maintain airway; administer oxygen. Control external bleeding. Elevate lower extremities 8-12 inches. Prevent loss of body heat. Transport immediately. Transport to nearest Trauma facility, using the most expeditious means available. Documentation Documentation Document scene on arrival Document any evidence noted on scene Document interaction with Law Enforcement, Coroner, or Medical Examiner Questions ?? Post-Test • • • • • 1. When arriving at a potential crime scene, the EMT should: A. Leave all the vehicle emergency lights and siren on until your reach the exact location of the call to announce your arrival B. Park directly in front of the address given so you can be easily seen C. Wait for law enforcement officers to arrive before entering the scene D. All of the above • • • 2. • 3. You evaluate specific areas of the body during a rapid trauma assessment to identify: A. The greatest life-threats to the patient B. All sites of bleeding C. All fracture sites D. Any threat that will require surgical intervention • • • If a patient is in shock, you would expect the skin to be: A. Cool and clammy C. Hot and dry B. Warm and dry D. Warm and moist • 4. The “Golden Hour” is a standard parameter for emergency care. The severely injured patient has the best chance for survival if: • A. The patient arrives at the emergency department within one hour of the injury B. Surgical intervention takes place within one hour of the injury C. Surgical intervention takes place within one hour after the patient’s arrival at the hospital D. The ambulance arrives at the scene within one hour of the injury • • • • • • • • • • • 5. External bleeding that is rapid, spurting with each heartbeat, and profuse is from a (n): A. Artery C. Capillary B. Vein D. All of the above 6. When should you assess the scene of an accident or injury: A. Only at the beginning of the call B. At the beginning and throughout the entire call C. Only when needed D. After the patient has been treated for life threatening injuries • • • • • • • • • • • • • • • 7. Calls to bar-rooms present the EMT with special challenges, including: A. Alcohol-intoxicated people making the situation unpredictable B. Friendships or feuds which may result in the further eruption of violence C. The dark atmosphere of the room especially if the EMT comes in from bright sunlight D. All of the above 8. A 16-year-old female patient received a gunshot wound to her abdomen. You should inspect and palpate her posterior region for: A. Vein distention C. Tenderness to the spine B. Paradoxical motion D. Muscular spasms 9. Body substance isolation (BSI) precautions that should be taken when there is a possibility of blood spatter include: A. Gloves C. Masks B. Protective eyewear D. All of the above 10. As you monitor the patient that you believe is going into shock, one of the last signs you should expect to see is: A. An increased pulse rate C. Increased respirations B. Decreased blood pressure D. Cool, clammy, pale skin Contact Information Renee Anderson andersr@inhs.org 509-232-8155