‘Gunshots & Stabbings’ An introduction to the management of pre-hospital trauma patients<br />By Dr. Nic Sparrow  MBBS, BS...
Overview / Aims<br />To discuss some of the general principles of managing penetrating trauma in the pre-hospital setting<...
The ‘CALL – OUT’<br />THINK SAFETY - SELF... Scene... and Survivors<br />Plan your route, make a slow & safe approach / pa...
Management of Penetrating Trauma – ATLS Approach<br />Pre-Hospital Care (PHC) Provider<br />Airway<br />Breathing<br />Cir...
(A) Airway / C-Spine Protection<br />PHC Provider<br />Rapid Assessment of  the Airway / C-spine is required<br />Remember...
‘Penetrating extremity trauma can quickly lead to Massive Haemorrhage  and death’ <br />
A Useful Piece of Pre-Hospital Equipment:<br /><ul><li> The CAT tourniquet can be used to control massive haemorrhagic los...
Facial / Mandibular #’s
Tracheal / laryngeal #’s
Expanding haematomas</li></ul>All can lead to airway     <br /> obstruction and death<br />Consider the risks of  Air Embo...
(A) Airway / C-Spine Protection<br /><ul><li>Inspect the mouth / clear the airway / head tilt chin lift or jaw thrust
Airway interventions depend upon the patient`s injuries, the level of skill and equipment of the provider:- </li></ul>Oxyg...
Intubation<br /><ul><li>A definitive airway should be considered in patients with:-</li></ul>	- GCS of 8 or below<br />	- ...
Surgical Cricothyroidotomy<br />Indicated when:-<br />Can’t ventilate / Can’t Intubate<br />Sedate Patient<br />Scalpel<br...
(B) Breathing<br />PHC Provider<br /><ul><li>Inspection – Tracheal position, distended neck veins, chest movement, respira...
Auscultation – Air entry, breath sounds, vocal fremitus
Percussion – Dull / hyperesonant
Measure – Respiratory rate & O2 saturations</li></li></ul><li>(B) Breathing<br /><ul><li>Life threatening conditions inclu...
Airway obstruction
Tension pneumothorax
Open pneumothorax
Massive Haemothorax
Instability of chest wall (flail Chest & contusions)
Cardiac Tamponade
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Gun Shots & Stabbings - An introduction to the management of pre-hospital trauma patients

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Introduction to the management of penetrating pre-hospital trauma.

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  • Massive Haemorrhage / C-spine Injury / Reduced GCS (head injury <9)
  • Gun Shots & Stabbings - An introduction to the management of pre-hospital trauma patients

    1. 1. ‘Gunshots & Stabbings’ An introduction to the management of pre-hospital trauma patients<br />By Dr. Nic Sparrow MBBS, BSc, MRCGP<br />Medical Director – Pre-Hospital Care World<br />www.phcworld.org<br />
    2. 2. Overview / Aims<br />To discuss some of the general principles of managing penetrating trauma in the pre-hospital setting<br />Look at some of the common injuries <br />Review some essential interventions and skills needed to treat patients<br />
    3. 3. The ‘CALL – OUT’<br />THINK SAFETY - SELF... Scene... and Survivors<br />Plan your route, make a slow & safe approach / park defensively. Await the arrival of the police... <br />Communicate arrival to control & other services <br />Assess & Approach only if it is safe (remember it’s a crime scene – don`t become a casualty)<br />
    4. 4. Management of Penetrating Trauma – ATLS Approach<br />Pre-Hospital Care (PHC) Provider<br />Airway<br />Breathing<br />Circulation<br />Disability<br />Exposure <br />Assessment is often done simultaneously<br />Always remember C-spine & Massive Haemorrhage Control<br />Ask yourself<br /> 1) What is the diagnosis ?<br />2) How severe is it ?<br />3) Can it be reversed ?<br />4) Is reversal needed now ?<br />
    5. 5. (A) Airway / C-Spine Protection<br />PHC Provider<br />Rapid Assessment of the Airway / C-spine is required<br />Remember C-spine / Massive Haemorrhage Control may pose an immediate threat to life and may need to take priority before airway<br />Bullet lodged close to the cervical spine<br />
    6. 6. ‘Penetrating extremity trauma can quickly lead to Massive Haemorrhage and death’ <br />
    7. 7. A Useful Piece of Pre-Hospital Equipment:<br /><ul><li> The CAT tourniquet can be used to control massive haemorrhagic loss in stabbed or shot patients</li></li></ul><li>(A) Airway / C-spine Protection<br />PHC PROVIDER<br /><ul><li>SECURE THE C-SPINE </li></ul>Inspect for:-<br /><ul><li>Foreign bodies
    8. 8. Facial / Mandibular #’s
    9. 9. Tracheal / laryngeal #’s
    10. 10. Expanding haematomas</li></ul>All can lead to airway <br /> obstruction and death<br />Consider the risks of Air Embolus in vascular injuries to the neck<br />
    11. 11. (A) Airway / C-Spine Protection<br /><ul><li>Inspect the mouth / clear the airway / head tilt chin lift or jaw thrust
    12. 12. Airway interventions depend upon the patient`s injuries, the level of skill and equipment of the provider:- </li></ul>Oxygen 15L (Reservoir Bag)<br />Oropharyngeal airway<br />Nasopharyngeal airway<br />Extraglottic Devices<br />Endotracheal intubation <br />Emergency Cricothyroidotomy<br />
    13. 13. Intubation<br /><ul><li>A definitive airway should be considered in patients with:-</li></ul> - GCS of 8 or below<br /> - Unstable #’s of mandible / maxilla<br /> - Inhalational burns<br /> - Tracheal or laryngeal injury <br /> - Penetrating injuries to the neck <br /> with expanding hematoma etc.<br />
    14. 14. Surgical Cricothyroidotomy<br />Indicated when:-<br />Can’t ventilate / Can’t Intubate<br />Sedate Patient<br />Scalpel<br />1cm Stab incision into the cricothyroid membrane<br />Insert Size 5-6 ET tube<br />Secure the ET tube<br />Definitive Tracheostomy will be required<br />
    15. 15. (B) Breathing<br />PHC Provider<br /><ul><li>Inspection – Tracheal position, distended neck veins, chest movement, respiratory rate
    16. 16. Auscultation – Air entry, breath sounds, vocal fremitus
    17. 17. Percussion – Dull / hyperesonant
    18. 18. Measure – Respiratory rate & O2 saturations</li></li></ul><li>(B) Breathing<br /><ul><li>Life threatening conditions include:- ( ATOMIC – TAO )
    19. 19. Airway obstruction
    20. 20. Tension pneumothorax
    21. 21. Open pneumothorax
    22. 22. Massive Haemothorax
    23. 23. Instability of chest wall (flail Chest & contusions)
    24. 24. Cardiac Tamponade
    25. 25. Tracheal or Bronchial Injury
    26. 26. Aortic / Oesophageal Rupture</li></li></ul><li>‘Posterior stab wound – what might you expect to see on x-ray ? ’<br />
    27. 27. Right Sided Pneumothorax<br />
    28. 28. Consider other possible Structures Injured e.g. oesophagus<br />
    29. 29. Large Right Haemothorax<br />
    30. 30. (C) Circulation<br /><ul><li>Haemorrhage is the predominant cause of preventable post-injury deaths. 90% of shock is haemorrhagic in trauma
    31. 31. ↓ GCS can be caused by ↓ cerebral perfusion secondary to haemorrhagic shock
    32. 32. Important to consider all possible injuries to organs or vessels in penetrating trauma</li></li></ul><li>(C) Circulation<br />Observation– inspect the scene and estimate blood loss, assess colour / temperature of the patient<br /><ul><li>Palpation – feel for peripheral pulses / strength, character and rate
    33. 33. Auscultation – heart sounds ? muffled
    34. 34. Check Manual Blood pressure on non-injured side</li></li></ul><li>Circulation - Interventions<br /><ul><li>Insert x2 large bore IV’s 14 – 16G
    35. 35. Do not place IV’s on the same side as the injury if possible
    36. 36. Intraosseous / sternal / femoral / central access may berequired in the profoundly shocked patient </li></li></ul><li>Circulation<br />Fluid Resuscitation:<br />Stage 1<br />X2 Ringers Lactate<br />Max (2000 ml)<br />Stage 2<br />X4 Gelofusin<br />Max (2000 ml)<br />Blood should be GIVEN after stage 1 if available<br />Maintain BP at no more than 90mmHg in penetrating injuries<br />
    37. 37. Never forget pelvic fractures as a cause for hypotension<br />Beware the ‘thirsty’<br />patient<br />Blood on the floor<br />Look for 4 more<br />(Chest / Abdomen / Pelvis / Femur)<br />
    38. 38. Disability / Exposure<br />DISABILITY<br /><ul><li>AVPU Scoring
    39. 39. Assess the GCS
    40. 40. Pupils
    41. 41. Neurological Deficit</li></ul>EXPOSURE<br /><ul><li>Remove clothing (save for forensics)</li></li></ul><li>

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