combat tactics trauma article

7/29/2019 Combat Tactics Trauma Article

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Trauma and Gunshot wounds:What you need to know to save a life.

Dr.MaurizioA.Miglietta

Introduction

Bythetimeyoufinishreadingthisstory,adozenAmericanswillhavediedfromatrauma

death.TraumaistheleadingkillerofAmericansfromoneto44yearsofage.Thereare

18deathsperhourfromtraumaticinjury.

Inthemilitarysetting,despitetheincreaseinfirepower,thenumberofdeathsduringwar

hasdecreased.InWorldWarII,30%oftheAmericansinjuredincombatdied.In

Vietnam,thisnumberdroppedto24%.InthewarinIraqandAfghanistan,about 10

percentofthoseinjuredhavedied.Thereductionofdeathscanbeattributedtobetter

traumasystems,timelyaccesstomedicalcare,andnewertraumaapproaches.Thisis

whyitisimportantforyoutoknowwhattodointheeventofatrauma.

Anunderstandingofwhattodoindifferenttraumascenarioscouldmakethedifference

betweenlifeanddeathforyouoryourpartner.Thisarticleoutlinessomebasic

informationonacutetraumacareandtreatmentofpenetratinginjuries.Unlessyouhave

thoughtabouthowyouaregoingtoreacttoaspecificevent,mistakescanhappenand

youdontwanttocausemoreharm.Notknowingwhattodoisaterriblefeelingandcan

costalife.Bytheendofthisarticle,youshouldhaveabetterunderstandingofgunshot

woundsandbeabletoinitiallycareforthem.

The Basics

Traumaisgenerallydividedintopenetratingorblunttrauma.Penetratingtraumarefers

togunshotwounds,stabwounds,andinjuryfromprojectiles.Blunttraumacaninclude

assaults,motorvehicleaccidents,falls,explosions,andotherforcemechanisms.This

articlewillmainlyfocusonpenetratinginjuriesbutappliestotheinitialcareofalltrauma.


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Whateverthecauseoftrauma,thereareafewbasicrulestoremember.Aneasywayto

remembertheapproachtoaninjuredpatientistheA,B,C,D,Es;Airway,Breathing,

Circulation,Disability,Exposure.SeeTable1.

A. AforAirwayreferstothevictimsmouthandbreathingpassage.Inanunconsciouspatient,thetongueisthemostcommoncauseofobstruction

oftheairway.Simplypositioningthevictimcanallowthemtobreathe.A

clearbreathingpassageisvitalbecauseoncethisisblocked,thevictim

heartwilleventuallystopbeatingwithoutoxygen.

B. Breferstobreathingmeaningisthepatientactivelybreathingandisthechestrisingandfallingsymmetricallywitheachbreath.Forexample,if

someoneisstabbedinthechestandonesideoftheirchesthasnobreath

soundsanddoesnotriseandfall,thereisusuallyaseriousproblemsuch

asalungcollapse.C. CstandsforCirculation.Assessingcirculationmeansassessingthepulseatthewrist,neck,orgroinandgettingabloodpressureifyouhaveaBP

cuff.Ifyoucanfeelapulseatthecarotidartery,itmeanstheblood

pressureisatleast60.

D. DreferstoDisabilityorneurologicaldeficit.Forexample,avictimshotintheneckorbackmaynotbemovingtheirarmsorlegs.

Thisusuallymeansthespinalcordhasbeeninjuredandmovingthe

patientcanmakeitworse.Allofthefindingsorwhatyouobserveabouta

traumavictimandspontaneousmovementsofextremitiesshouldbe

communicatedtothehospitalstaff.

E. EstandsforExposure.Youneverwanttomissagunshotwoundorstabwoundasthiscanhavedeadlyconsequences.Itisveryeasytomissa

gunshotinsomeonesarmpitorbetweenthebuttocks.Ifyoudont

specificallylookthere,youwillmissit.Fullyexposingthepatientand

checkingeveryonewillensureyouhaventmissedanything.

The Golden Hour

TheGoldenHourisatermanyoneatriskforinjuryshouldbeveryfamiliarwith.Itrefers

totheideathatsurvivalisimprovedwhencriticalvictimsaremanagedbyaspecialized


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teamasrapidlyaspossible.Itisnotmeanttodenoteexactly60minutesbuttoimplyan

urgencytoseekappropriatemedicalcareandnotwasteprecioustimeinthefield.

Intheciviliansetting,EmergencyMedicalServices(EMS)providesanimportantrolein

thecareoftrauma.Inthemilitarysettings,yourmedicsandevac/rescuecrewswillserve

inthiscapacity.EMSprovidersareexpertsinextricatingvictimsofmotorvehicle

accidentsandtreatingcertainlife-threateninginjuries.However,severalstudiesare

showingthatincreasedtimespentinthefieldwithaseveretraumapatientmaynotthe

besttreatment. Yourchanceofdyingcandoubleincertainsituationswithmaneuversperformedinthefield.ThegoalofEMSoranypre-hospitalprovideristogettheinjured

patienttotheappropriatetraumahospitalasquicklyapossible.Takingintoaccountthat

EMShastobecontacted,thendeployaunitandtheninitiallytreatthevictiminthefield;

asignificantportionofyourGoldenHourisalreadyconsumed.Intheurbansetting,knowingwherethenearesttraumacenterswiththebestandfastestroutescanbe

crucialtosurvival.Forexample,becognizantthatthetraumacenter10blocksawaymay

nothavethebestcapabilitiesandrequiresatripacrossabusycongestedarea.Instead,

goingtothetraumacenter15minutesintheoppositedirectionmaybeabetteroption.

Evenamongtraumacenters,therearedifferentlevelsofexpertiseandcapabilities.

Level1traumacentersrepresentthehighestlevelandhave24hoursurgeonsanda

dedicatedteam.TheLevel2and3centersoftendonothavein-housecoverage;

meaningyoursurgeonwillhavetocomeinfromhometotakecareofbleeding.

RemembertheGoldenHour.

Thereare3peaksofdeathwhenitcomestodeathsfollowingtrauma.Thefirstoccursat

thesceneofinjury.Forexample,peoplewhodieatthesceneofamotorvehicleaccident

havetypicallysustainedsuchsevereheadorspinalcordinjuryormassivebloodvessel

injurythattheydieatthescene.Safetyfeaturessuchasseat-beltsandbulletproofvests

havereducedthisinitialpeakofdeath.Inpenetratingtrauma,victimsofgunshotwounds

whodieatthescenehavetypicallysustainedGSWtothecheststrikingtheheartor

majorbloodvessel.Eveninthebestofhands,thesevictimsaretypicallyunsalvageable.

Thesecondpeakofdeathoccurswithin6hoursofinjuryandstemsfrominternal

bleedingandbrainswelling.AregionaltraumasystemofEmergencyMedicalServices

andbetteraccesstoTraumaCentershashelpedtoreducethispeak.Thethirdpeakof

deathisafewweeksafterinjuryandoccursintheIntensiveCareUnitfrominfectionand

multisystemorganfailure.


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Where do people heavily bleed? How long does it take?

Themainprincipleoffieldtraumacareforthelaypersonistostopongoingbloodloss.

Applyingdirectpressureonableedingwoundisthemosteffectivetechnique.This

simplemaneuverwillalmostalwaysstopthebleeding. Theaverageadultmalehas5literofbloodinthebody.Typicallybloodpressurebegins

todrop(hypotension)when2030%islost.Deathcanoccurwhen40%ofbloodloss

occursandthevolumeisnotreplaced.Therearefiveareaswherepeoplecanbleed

largeamountscausingshock.Theyarethechest,abdomen,pelvis/retroperitoneum,

longbones(eg.Femur)andatthescene(bleedingfromanopenwoundontothefloor).

1. CHESTBLEEDING:Massivechestbleedingtypicallycomesfromthebloodvesselsthatrunfromthecenterofthechestcavityuptothehead

anddowntotheabdomen.Theselargebloodvesselscalledtheaorta

andthevenacavatakebloodtoandfromtheheart.Theheartandthe

lungscanalsobeinvolvedandcanbleedheavily.Theribcagecanalso

bleedifoneofthebloodvesselsunderneatheachribisinjuredbutthis

bleedingtendstobeataslowerrate.

2. ABDOMINALBLEEDING:Abdominalbleedingcanoccurfromlargesolidorganssuchasyourliver,spleenorkidneyaswellasthebloodvessels

feedingtheintestines.Alloftheseinternalorganshavearichblood

supplyandwheninjuredcanbleedlargeamounts.Thebleedingtothese

structuresisunabletobecontrolledinthefieldandthesepatientsrequire

emergenttransfertoanacutecaresetting.

3. PELVIS/RETROPERITONEALBLEEDING:Pelvis/retroperitonealbleedingoccurswhenthepelvis,whichisreallyaringofbones,isbroken.

Thebloodvesselsthatrunalongthebonesaretornandbleedheavily.

Theretroperitoneumistheareabehindtheabdomenandyourintestines.

Thisiswheretheverylargebloodvessels,namelytheaortaandinferior

venacava,arelocated.Wheneitherofthesestructuresisinjured,

bleedingisoftenmassive.Naturepurposelyplacedthesestructuresinthe

middleofourbodiesandinfrontofthevertebralcolumntospecifically


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protectthemfrominjury.Notmuchcanbedoneinthefieldtocontrolthis

typeofbleeding.

4. LONGBONEBLEEDING:Bleedingfromthelongthighbonesofthelegcanbesignificant.Bleedingcanbecontrolledinextremityinjurieswith

heavymanualcompression.Thetypicalmechanismisyourlegbeing

pinnedintothedashboardduringamotorvehiclecrash.Agunshot

woundtothelegcaneitherfracturethefemurorhitamajorbloodvessel

causinghemorrhage.Onecanlosealiterandahalfofbloodintoeach

thighwithafemurfracture.Reducingthefracturecanhelpminimizethis

andunkinkanybloodvesselsthatprovidescirculationtothelowerleg.

5. OPENWOUNDBLEEDING:Ifapersonhasnotbleedintooneoftheinternalcavitiesofthebodysuchasthechestorabdomenorareas

outlinedabove,theonlyotherplacethebloodcouldhavegoneisonthe

floor.Openwoundcanbleedoutandthatswhyitisimportantto

communicatetothedoctorstheamountofbloodlossinthefield.

To drop someone instantaneouslyInordertokillsomeoneorincapacitatetheminstantaneously,youtypicallyneedtostrike

thecentralnervoussystem(brainorspinalcord)orheart/majorbloodvessel.Themajor

superficialbloodvesselsthatareatriskforinjuryanddeatharethecarotid,

radial/brachial,femoral,andpoplitealvessels.Themajordeepbloodvesselsarethe

aorta,iliacarteryandvein,andvenacava.Evenagunshottothebrainsometimesdoes

notincapacitateavictim.Thebullettraversingbothhemispheresorpartsofthebrainwill

typicallydropsomeone.Whenitcomestobloodvessels,strikingthemajorchestblood

vesselswillalsoincapacitatesomeonealmostinstantaneously.

How to control bleedingPressure,pressure,pressure.Itcannotbeoverstatedthatsimplyputtingdirectpressure

onableedingwoundwillstoporcontrolmostbleeding.Youshouldpresswithwhatever

amountofforceittakesforthebleedingtoslowdownandhopefullystop.Ifdirect

pressuredoesntwork,compressingthenearestarteryfeedingthatareaoftenworks.

Thisiswhyitisimportanttolearnthebasicanatomicalpathofthemajorbloodvessels


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sothatyouknowwheretopressandoccludethem.Ifthesestepsdontwork,a

tourniquetmaybeneeded.

TourniquetsTheuseoftourniquetsissomewhatcontroversialandshouldnotbeafirstline

maneuver.Theissuewithtourniquetisthattheystopbloodflowtoanystructurebelowit.

Thereforeyouarestealingoxygenfromgettingthereandpreventingtoxicmetabolites

fromleaving.Thiscancauseorganfailureandpossiblydeathwhenthetourniquetis

released.ThewayIlookatitisifbleedingcantbecontrolledwithpressure,youhaveno

choice.Wecandealwithcomplicationslater.

Mostextremitybleedingcanbecontrolledwithdirectpressure.Whenbleedingis

uncontrolledwithpressure,atourniquetshouldbeused.Ifyoudoneedtoplaceatourniquet,itshouldbebroadandtightenough.Whatevertypeoftourniquetused,it

shouldbeplacedasfardownaspossibleandnotoverajointspace(asthearterydives

deephereandcantbecompressedbythebone).Inaddition,atourniquetshouldnotbe

appliedoverexposedmusclewithoutskin(toavoidslipping).Again,itshouldbe

evaluatedandremovedassoonaspossibleandconvertedtoapressurebandageif

possible.Tourniquetsareverysuccessfulatcontrollingextremitybleeding.Like

everythinginTrauma,timeisoftheessence.Musclecanonlybedeprivedofcirculation

andoxygenforonly46hours.Afterthat,themusclesandnerveshavetypicallydied

andthereforeamputationofthelimbisrequired.Releasingthetourniquetattimescan

buyyoumoretime,butatthecostofbloodloss.Remember,itslifeoverlimb.

Tourniquetscanbeverypainful.Allyouhavetodoisrememberadoctorsvisitwhen

theypumpupthebloodpressurecuffforafewseconds.Thistendstohurtuntilthecuff

isreleased.Animportantpointtorememberwithtourniquetsisthattheyarenotwithout

complications;mostimportantly,reperfusionsyndrome.Asthetoxicmetabolitesbuildup

andoxygenisdeprivedintheareabelowthetourniquet,victimscamebecomeverysick

andevendie.

Ipersonallythinkastandardbloodpressure(BP)cuffifthebesttourniquetsincealmost

everyoneknowshowtoapplyitanditcanberemovedeasily.Yougenerallyhaveto

pumpuptheBPnumbertotwiceyourbloodpressure.SoifyourBPis120/80,youneed

topumpituptoanumberof220240atleast.


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GUNSHOT WOUNDS

Inordertobetterunderstandthedamageinflictedtothebodybybullets,itisimportantto

understandthedifferentcomponentsofwounding.Bulletscausedamagefromboth

directandindirectmechanisms.Thedirectmechanismsincludethecuttingfromthe

originalbulletandfragmentspassingthroughflesh.Thisisthemaincauseofdamage

fromlowvelocitybullets.Indirectmechanismsincludestretchanddisplacementofflesh

fromthebulletcavitationeffect.Thisismainlyseenwithmediumtohighvelocity

weapons.

Thereare3maincomponentsofwoundingwithgunshotwounds.

1. Penetration:Penetrationreferstothefleshwhichisdestroyedordisruptedbythepassingprojectile.Abulletfiredattheabdomenmust

penetrateapproximately7inchesinordertoreachthemajorblood

vesselstocausesignificantlybleedingandsometimesinstantaneous

death.

2. Cavitationisthesecondcomponentandconsistsofashock-wavelikeeffect.Temporarycavitationcanbeupto10timesthediameterofa

mediumtohighvelocitybullet.Thepermanentcavitationistheholeleftby

thebulletitself.Damagewilldependontheelasticityoftheorganor

tissue.Muscle,bloodvessels,lungandbowelarerelativelyelasticand

thereforehavealesspermanentcavitationeffect.Liverandbrainonthe

otherhandarerelativelyinelasticandcavitationbecomespermanent

resultinginsignificantdamage.

3. Fragmentationisthelastcomponent.Projectilefragmentsorsecondaryfragmentssuchasbonearesentoffandcreatetheirownpathsthrough

flesh.Thisisamajorcauseoftissuedisruptionwithhighvelocitybullets.

Neverunderestimatethesizeandtrajectoryofagunshotwound.Gunshotwounds,with

theexceptionofshotgunwounds,appearrelativelysmallandunimpressive.Butbeware.

Theinternaldamagefromtheabovemechanismsisquitesignificant.Inaddition,never

assumeabullettravelsinastraightline.Wehaveseenhundredsofcasesofthemost


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amazingtrajectories.Forexample,Ihaveseenapatientshotinthelegwiththebullet

sittinginhischest.Dontnecessarilyfocusonthewounditself.

MANAGEMENT OF GUNSHOT WOUNDS

Thebasictreatmentofgunshotwoundsdependsonthearea(s)struck.Generally,

gunshotwoundsshouldbecoveredbyadrydressingoracleartransparentdressingif

available.Manualpressureshouldbeappliedifthewoundisbleeding.Onceata

definitivecarecenter,wewillcleanthewound,possibledebridesomeedges,and

changethedressingsdaily.Agunshotisneversuturedclosedastheinfectionrateis

veryhigh.Bulletsdragclothingintothewoundandalongthebullettrack.Sinceclothing

isofcoursenotsterile,thewoundispronetoinfectionifclosed.Openwoundsalmost

nevergetinfected.

Wewillnowgooverhowtohandlegunshotwoundsfromhead-to-toe.

GSW to HEADGunshotwoundstotheheadaretypicallyfatalifthebulletcrossesbothofthebrain

hemispheresorhitthebrainstemwhichisresponsibleforcontrolofbasicvitals.We

haveallseenmiraculouscaseswithGSWtotheheadwithvictimswalkingaroundand

talking.Thereisnorealtreatmentinthefieldtotreatthis.Headelevationorseated

positioningandrapidtransporttoatraumacenterwithneurosurgicalcapabilitiesiskey.

GSW to FACE & NECKGunshotwoundstothefaceandneckareoftentroublesome.Sinceyourfaceandneck

haveexcellentcirculation,bleedingisoftenheavy.Inaddition,theairwaycanbecome

obstructedbyblood,teeth,andswelling.Manualpressureshouldbeappliedtoa

bleedingwoundandleavethevictimintheuprightposition.Directpressureshouldbe

strongenoughtostopthebleeding.Avoidpressingoveralargeareaasyoucan

compromisebloodflowtothebrainorshiftthetracheacausinganairwayobstruction.

EmergencyMedicalServicesoftentimesplaceacervicalcollarandback-boardto

immobilizeagunshotvictimbyprotocol.However,theincidenceofspinalcordinjury

causedbymovementisexceedinglyrareandthereforetimeshouldnotbewastedwith

immobilizationofthevictim.Paralysisfollowinggunshotwoundshappens


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instantaneouslywhenthebulletripsthroughthespinalcord.Itgenerallydoesnotoccur

withmovingfracturesorothermeans.

GSW to CHEST & BACKGunshotwoundstothechestcanhitavarietyoforgans.Thelungs,heart,andmajor

bloodvesselscanbestruckandtypicallycanbefatalifnotimmediatelytreated.A

collapsedlungorpneumothoraxwillmanifestwithdifficultybreathing.Atension

pneumothoraxisacollapsedlungthatisbuildinguppressureandcausingcollapseof

adjacentorgans.Ahemothoraxisbloodinthechestcavity.Uponarrivaltoatrauma

center,thetraumateamwillplaceachesttubetorelievetheseconditionsanddrain

blood.

Suckingchestwoundsoccurwhenairisseentravelinginandoutofawoundwitheachbreath.Nevercompletelyoccludethesesuckingchestwoundsasyoucancauseabuild

upofpressurewithinthechestandcausealife-threateningtensionpneumothorax.

Suckingchestwoundsareveryrareintheciviliansettingwithlowvelocitybulletsbut

maybeseenwithmediumandhighvelocitybullets.Athree-sidedtapetechniquewithan

occlusivedressingisindicatedtomanagethesewounds.

Directpressureshouldbeappliedtoableedingwoundbutitisoftenhardtocompress

chestbleedingasthestructuresthatarebleedingareprotectedbythebonyribcage.If

youaretrained,needledecompressionshouldbeusedifyoususpectatension

pneumothorax.

GSW to ABDOMENGunshotwoundstotheabdomencancauseboweldamageaswellassignificant

bleeding.Manualpressurewithadrydressingisindicatedforanactivelybleeding

woundbutoftentimesitisdifficulttocompresstheinternalbleedingsource.Thisiswhyit

isimportanttotransporttoatraumacenterASAPwhereatraumasurgeoncangoinand

operateimmediately.

GSW to the extremitiesArmorleggunshotwoundscanbleedheavilyifabloodvesselisstruck.Directmanual

pressureisindicatedtoinitiallycontrolbleeding.Aninjuredbloodvesselcaneither

bleedexternallyorsometimesclotandblockbloodflowtotheremainderofthe


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extremity.Bothareemergenciesrequiringasurgeon.Youshouldpresshardenoughto

stopthebleeding.Tourniquets,asdescribedabove,maysometimesbeneeded.Large

skindefects,fromforexampleshotgunwounds,mayrequiretopicalclottingagentsto

helpcontrolbleeding.Typically,directpressureisalmostalwaysenough.

Take-Home Points

Themostimportanttake-homemessagefromthisarticleshouldbeanappreciationfor

time.Theclockbeginsrunningwiththeinitialtraumaandeveryminutethereaftercounts.

TransportingapatientaftertheA,B,Csandafterinitiallybleedingiscontrolledisthe

keytosuccess.Foraninjuredpatient,gettingtoadedicatedtraumacenterandperhaps

anoperatingroomwilldirectlypredictsurvival.Havinganunderstandingofbasic

mechanismsofinjuryandhowtotreatspecificinjurieswillincreasethelikelihoodofa

betteroutcome.Ataminimum,youshouldbetrainedasafirstresponderandbe

certifiedinBasicLifeSupport/CPR.

Asimportantasitistoaideothers,youneedtobeawareoftheimportanceofprotecting

yourself.Alwaysbepreparedandcarryaminimumamountofmedicalsupplies.Ifyour

occupationrequiresyoutocarryaknifeorgun,thereisnoexcusenottocarrysome

medicalsupplies.Althoughamedicalbaginyourcartrunkmaybeuseful,havingthe

necessarymedicalsuppliesonyouisfarmoreoptimalandcouldmeanthedifferencebetweenlifeanddeath.


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TABLE1

TheBasics Whattoevaluate Actiontotake

A:Airway Assesstheairway

Look,listen,andfeel

Openthemouthandairway

Removeanyforeignbodies

orlooseteeth

Useheadtilt-chinliftorjaw

thrustmaneuverifcervical

spineinjuryissuspected.

B:Breathing Assessbreathing

Isthechestrising&falling?

Provideassisted

respirationsifthepatientis

notbreathing

C:Circulation Checkpulses StartCPRifyoudontfeela

pulse

D:Disability Isthevictimabletotalk?

Isvictimmoving

extremities?

Preventneurologicalinjury

bymakingsurenotto

unnecessarilymovethe

patient,especiallydontturn

thehead.

E:Exposure Lookforallstabwounds

andgunshotwoundsinarmpits,groins,etc.

Directpressureifbleeding

woundDonotremoveimpaled

objects.

combat tactics trauma article

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