‘Gunshots & Stabbings’ An introduction to the management of pre-hospital trauma patients By Dr. Nic Sparrow MBBS, BSc, MRCGP Medical Director – Pre-Hospital Care World www.phcworld.org
Overview / Aims To discuss some of the general principles of managing penetrating trauma in the pre-hospital setting Look at some of the common injuries Review some essential interventions and skills needed to treat patients
The ‘CALL – OUT’ THINK SAFETY - SELF... Scene... and Survivors Plan your route, make a slow & safe approach / park defensively. Await the arrival of the police... Communicate arrival to control & other services Assess & Approach only if it is safe (remember it’s a crime scene – don`t become a casualty)
Management of Penetrating Trauma – ATLS Approach Pre-Hospital Care (PHC) Provider Airway Breathing Circulation Disability Exposure Assessment is often done simultaneously Always remember C-spine & Massive Haemorrhage Control Ask yourself 1) What is the diagnosis ? 2) How severe is it ? 3) Can it be reversed ? 4) Is reversal needed now ?
(A) Airway / C-Spine Protection PHC Provider Rapid Assessment of the Airway / C-spine is required Remember C-spine / Massive Haemorrhage Control may pose an immediate threat to life and may need to take priority before airway Bullet lodged close to the cervical spine
‘Penetrating extremity trauma can quickly lead to Massive Haemorrhage and death’
A definitive airway should be considered in patients with:-
- GCS of 8 or below - Unstable #’s of mandible / maxilla - Inhalational burns - Tracheal or laryngeal injury - Penetrating injuries to the neck with expanding hematoma etc.
Surgical Cricothyroidotomy Indicated when:- Can’t ventilate / Can’t Intubate Sedate Patient Scalpel 1cm Stab incision into the cricothyroid membrane Insert Size 5-6 ET tube Secure the ET tube Definitive Tracheostomy will be required
Check Manual Blood pressure on non-injured side
Circulation - Interventions
Insert x2 large bore IV’s 14 – 16G
Do not place IV’s on the same side as the injury if possible
Intraosseous / sternal / femoral / central access may berequired in the profoundly shocked patient
Circulation Fluid Resuscitation: Stage 1 X2 Ringers Lactate Max (2000 ml) Stage 2 X4 Gelofusin Max (2000 ml) Blood should be GIVEN after stage 1 if available Maintain BP at no more than 90mmHg in penetrating injuries
Never forget pelvic fractures as a cause for hypotension Beware the ‘thirsty’ patient Blood on the floor Look for 4 more (Chest / Abdomen / Pelvis / Femur)