ems - inhs health training · ems live@nite presentation, all certificates will be printed by...
TRANSCRIPT
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Spokane County EMS
Penetrating Trauma
Overview
• Review of Kinematics
• Physics of Penetrating Trauma
• Pathophysiology of a gunshot wound
• What is cavitation
• Index of suspicion
• Wound Characteristics
• Treatment
• Working with law enforcement
Physics of Penetrating Trauma
• Remember the Kinetic Energy Equation??
• Greater the mass the greater the energy– Double mass= Double KE
• Greater the speed the greater the engery– Double speed = 4x increase in KE
2
)()( 2speedVelocityweightMassKE
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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
Maybe they are not just shot…..
What if it doesn’t enter the body?
• 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
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They are all different!
Pathophysiology of a gunshot wound
• 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.
Visual Learning
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The bullet does cause damage but is that it?
• 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
Apply what you see here…..
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Low Velocity
• Objects– Knives, Ice-picks, Arrows
– Flying objects or debris
• Injury limited to tissue impacted– Object pathway
– Object twisting or moved
– Oblique angle
2 Inches
Index of Suspicion
• 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
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Index of Suspicion
• Lungs– Air in lung absorbs energy
– Pneumothorax or hemothorax
• Bone– Resists displacement until it shatters
– Alters projectile path
• Extremities– Injury limited to resiliency of tissue– 60-80% of injuries with <10% mortality
Index of Suspicion
• 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
• Neck– Damages Trachea and
Blood Vessels
– Neurological problems
– Sucking neck wound
• Head– Cavitational energy trapped
inside skull
– Serious bleeding/Death
What are your concerns?
• What lethal injury can this person have?
• What would be your first priority?
• Does this injury require c-spine?
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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
What good does a great head-to-toe assessment do?
• What type of injury does this look like?
• What could have caused this?
• Guess we should go look to find clues!
When to use an occlusive dressing
• Open Chest Wound– May or may not be a sucking sound– Seal wound as soon as possible
• Gloved hand • Occlusive dressing
– Think entrance and exit wounds
– High Flow O2– Treat for Shock– Monitor patient for any complications or buildup of
pressure. If S/S of tension pneumothorax appear you need to “burp” the dressing to relieve the pressure
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Tension Pneumothorax
Penetrating injuries and C-spine
• Would you need to c-spine this injury?
• How would you do it?
• What would you want to know if you were going to not c-spine?
PHTLS
• PHTLS 8th edition guidelines
• A little different than what we have done in the past!
• How many agencies out there are doing this?
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• Impaled Objects– Low-energy
– Dangerous to remove
– DO NOT REMOVE• UNLESS
– In Cheek/ Airway Obstruction
– Interferes with CPR: ASSESS!!!
Special Concerns with Penetrating Trauma
Treatment is pretty straight forward right? • H-ABC
– Life threatening hemorrhage
– Airway
– Breathing
– Circulation • They still take priority over minor bleeding or injuries
• Direct pressure – Stop the bleeding!
– If pressure is not working tourniquet
• Consider occlusive dressing for chest and neck wounds
With Penetrating Injuries Comes the Chance of Working with Police.
Entering the Scene
• You must try to carry out your duties with minimal impact on potential evidence
• Entry or exit to the scene that was not used by a suspect
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Care on the Scene of a Crime
• Be observant and look for hazards
• Touch only what is required for patient care
• Wear gloves
• Watch where you step
• Bring only necessary equipment and personnel only
• Document your observations
Treatment and Assessment
• DO NOT– Cut through bullet holes or stab wounds in clothing
– Shake or turn clothing inside out
– Leave medical packaging or gloves at the scene
– Rely on your memory
– Alter position of evidence unless absolutely necessary
– Step in blood stains or splattered blood
– Touch weapons or bullets
Document, Document, and Document
• Note and document in writing the following:– evidence of forced entry
– room layout
– location of patient
– location of weapons or potential weapons
– signs of struggle
– bullet casings or cartridges
What other things do you think should be documented?
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Your Patient:Assessment and Treatment
• Dangers?
• What areas are of concern?
• Treatment?
• Transport?
Questions?
POST-TEST
1. What type of weapon is a Medium Energy/Velocity weapon?
A. ArrowB. Assault RifleC. Knife D. Shotgun
2. Which of the following injuries can patients wearing body armor sustain?
A. Myocardial ContusionB. Rib FracturesC. Pulmonary ContusionsD. All of the above
3. Which of the following injuries would require an occlusive dressing?
A. Entrance wound on the right thighB. Impaled fork in the left cheekC. Stab wound to the right lateral chest wallD. GSW to the right index finger
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4. When is it ok to remove an impaled object?A. When you need to fit them in the ambulanceB. When it interferes with CPRC. When it is in the neckD. None of the above
5. What should you NOT do at a crime scene?A. Cut through bullet holes or stab wounds in clothingB. Play with the gun or knifeC. Step in the blood stains or splattersD. All of the above
SECRET QUESTION
What is the Kinetic Energy Equation ?
Special thanks to
Sheila Crow
Stitchin’ Dreams Embroidery
For providing our Secret Question prize
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Questions?
Contact: Samantha Roberts509-242-4264
[email protected]: 509-232-8344
Updates Please
EMS Live@Nite presentation, all certificates will be printed by participants or their agency. The
certificate template will be available through the health training website at the same location as all presentation downloads. It will be posted the day
after each monthly presentation.
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