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Gun Shots & Stabbings - An introduction to the management of pre-hospital trauma patients
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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.

Introduction to the management of penetrating pre-hospital trauma.

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  • Massive Haemorrhage / C-spine Injury / Reduced GCS (head injury <9)
  • Transcript

    • 1. ‘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
    • 2. 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
    • 3. 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)
    • 4. 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 ?
    • 5. (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
    • 6. ‘Penetrating extremity trauma can quickly lead to Massive Haemorrhage and death’
    • 7. A Useful Piece of Pre-Hospital Equipment:
      • The CAT tourniquet can be used to control massive haemorrhagic loss in stabbed or shot patients
    • (A) Airway / C-spine Protection
      PHC PROVIDER
      • SECURE THE C-SPINE
      Inspect for:-
      • Foreign bodies
      • 8. Facial / Mandibular #’s
      • 9. Tracheal / laryngeal #’s
      • 10. Expanding haematomas
      All can lead to airway
      obstruction and death
      Consider the risks of Air Embolus in vascular injuries to the neck
    • 11. (A) Airway / C-Spine Protection
      • Inspect the mouth / clear the airway / head tilt chin lift or jaw thrust
      • 12. Airway interventions depend upon the patient`s injuries, the level of skill and equipment of the provider:-
      Oxygen 15L (Reservoir Bag)
      Oropharyngeal airway
      Nasopharyngeal airway
      Extraglottic Devices
      Endotracheal intubation
      Emergency Cricothyroidotomy
    • 13. Intubation
      • 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.
    • 14. 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
    • 15. (B) Breathing
      PHC Provider
      • Inspection – Tracheal position, distended neck veins, chest movement, respiratory rate
      • 16. Auscultation – Air entry, breath sounds, vocal fremitus
      • 17. Percussion – Dull / hyperesonant
      • 18. Measure – Respiratory rate & O2 saturations
    • (B) Breathing
      • Life threatening conditions include:- ( ATOMIC – TAO )
      • 19. Airway obstruction
      • 20. Tension pneumothorax
      • 21. Open pneumothorax
      • 22. Massive Haemothorax
      • 23. Instability of chest wall (flail Chest & contusions)
      • 24. Cardiac Tamponade
      • 25. Tracheal or Bronchial Injury
      • 26. Aortic / Oesophageal Rupture
    • ‘Posterior stab wound – what might you expect to see on x-ray ? ’
    • 27. Right Sided Pneumothorax
    • 28. Consider other possible Structures Injured e.g. oesophagus
    • 29. Large Right Haemothorax
    • 30. (C) Circulation
      • Haemorrhage is the predominant cause of preventable post-injury deaths. 90% of shock is haemorrhagic in trauma
      • 31. ↓ GCS can be caused by ↓ cerebral perfusion secondary to haemorrhagic shock
      • 32. Important to consider all possible injuries to organs or vessels in penetrating trauma
    • (C) Circulation
      Observation– inspect the scene and estimate blood loss, assess colour / temperature of the patient
      • Palpation – feel for peripheral pulses / strength, character and rate
      • 33. Auscultation – heart sounds ? muffled
      • 34. Check Manual Blood pressure on non-injured side
    • Circulation - Interventions
      • Insert x2 large bore IV’s 14 – 16G
      • 35. Do not place IV’s on the same side as the injury if possible
      • 36. 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
    • 37. 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)
    • 38. Disability / Exposure
      DISABILITY
      EXPOSURE
      • Remove clothing (save for forensics)

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