Download Gunshot wounds - INHS Health Training

Gunshot wounds
Warning: This
presentation
has extremely
graphic
pictures!
Richard P. Kness, EMT- P
Objectives
After this lesson the student will be
able to:
List scene safety issues
Describe procedures to protect
crime scene evidence
recognize signs and symptoms of a
gunshot wound
categorize treatment for gunshot
wounds based on location and travel
of bullet
Document scene and care provided
Gunshot Wounds
Injuries created by medium or highvelocity weapons
Scene
Size-Up
Overall Assessment Scheme
Scene Size-Up
Initial Assessment
Trauma
Physical Exam
Vital Signs &
SAMPLE History
HOSP
Detailed
Physical Exam
Ongoing
Assessment
Scene Size-Up
Determining any threats to your own
safety or to the safety of your patients
or bystanders, to determine the
nature of the call, and to decide if you
will need additional help
Scene Safety
Scene Safety
Protect bystanders (prevent them
from becoming patients).
Never enter an unsafe scene.
Make scene safe or call for
someone who can.
The “Danger zone” may be far
reaching when a gun is involved
Scene Violence
Use scene clues:
Fighting
Loud voices
Alcohol/drug use
Unusual silence
Prior experience
Crime Scenes and Violence
Every Gun shot wound is considered a crime scene
until investigated by Law Enforcement
Crime Scenes and Violence
Work with Law Enforcement: (Don’t be a
“mobile evidence destruction unit”)
If possible do not disturb evidence:
Weapons
Clothing
damaged doors, or windows where
entrance was made
Blood pools or tracked blood
Other considerations?
Body
Substance
Isolation
Body Substance Isolation
Anticipate the need for BSI.
Always have BSI equipment available.
Use appropriate equipment to prevent
exposure.
Gloves
Face and eye protection
Gown
Assessment
of the
Trauma
Patient
Overall Assessment Scheme
Scene Size-Up
Initial Assessment
Trauma
Physical Exam
Vital Signs &
SAMPLE History
HOSP
Detailed
Physical Exam
Ongoing
Assessment
Assessing the Trauma Patient
Is there a significant mechanism of
injury?
Yes
No
Perform a rapid
assessment.
Perform a
focused
assessment.
Mechanism of Injury
Mechanism of Injury
Gunshot wounds
Mechanism of Injury
The physical event that caused an
injury (knife wound, gun shot wound,
motor vehicle accident, etc.)
Mechanism of Injury:
Penetrating Trauma
Velocity
Low velocity–knife
Medium velocity–handgun, shotgun
(generally less than 2,000 feet-per-minute)
High velocity–rifle (generally greater than
2,000 feet-per-minute)
Body region penetrated
Exit wounds
Wound ballistics
(Kinematics)
Wound Ballistics:
Medium and High velocity wounds
Factors that contribute to tissue
damage include:
Bullet size: The larger the bullet, the
more resistance and the larger the
permanent tract
Bullet deformity: Hollow point and soft
nose flatten out on impact, resulting in a
larger surface area involved.
Wound Ballistics:
Medium and High velocity wounds
tissue damage continued:
Semijacket: The jacket expands and
adds to the surface area
Tumbling: Tumbling of the bullet causes
a wider path of destruction
Yaw: The bullet can oscillate vertically
and horizontally (wobble) about its axis,
resulting in a larger surface area
presenting to the tissue.
Gunshot Wounds: Cavitation
To what is cavitation (shock wave)
related?
Gunshot Wounds
Entrance and exit wounds
Wound Ballistics:
Medium and High velocity wounds
The wound consists of three parts:
Entry wound: Usually smaller than the
exit wound
Exit wound: Not all gunshot wounds will
have exit wounds and on occasion there
be multiple exit wounds due to
fragmentation of bone or the bullet.
Generally the exit wound is larger and
has ragged edges.
Entrance and Exit Wounds
Wound Ballistics:
Medium and High velocity wounds
The wound consists of three parts:
Internal wound: Medium-velocity bullets
inflict damage primarily by damaging
tissue that the bullet contacts; Highvelocity bullets inflict damage by tissue
contact and transfer of kinetic energy
(the shock wave producing a temporary
cavity) to surrounding tissues
Mechanism of Injury: Penetrating Trauma
Gunshot wound
trauma injuries
Penetrating Trauma Injuries
Head: The skull is a closed space, thus
presenting some unique situations:
The shock wave has no place to go therefore
the brain tissue can be compressed.
If the forces are strong enough the skull may
explode from the inside out.
A medium velocity bullet may follow the
curvature of the interior of the skull. This path
can produce significant damage
Punctures/Penetrations (Gunshot wounds)
Punctures/Penetrations (Gunshot wounds)
Penetrating Trauma Injuries
Thorax: Three major groups of structures
inside the thoracic cavity must be
considered in evaluating a penetrating
injury to the chest:
Lungs: Less dense tissue so injuries are
generally from the bullet tract and less so from a
shock wave. Serious injuries include a
pneumothroax or hemothorax
Penetrating Trauma Injuries
Thorax:
Vasular: Blood and muscle is more dense than
lung tissue, therefore it is more susceptible to
shock waves in addition to the bullet track.
Injuries include damage to the aorta and the
superior vena cava as well as injury to the heart
muscle.
Penetrating Trauma Injuries
Thorax:
Gastrointestinal: The esophagus is located in
the thorax and may be injured by the bullet track
Injuries include damage to the esophagus as
well as spilling any contents into the thoracic
cavity which can lead to infection.
Punctures/Penetrations (Gunshot wounds)
Penetrating Trauma Injuries
Abdomen: The abdomen contains
structures of three types: Air filled, solid
and bony.
Gastrointestinal: The majority of the GI system
is located in the abdomen. Most of the GI tract
structures are considered to be air filled.
Injuries include damage to the GI system
structures as well as spilling any contents into
the abdominal cavity which can lead to
infection.
Penetrating Trauma Injuries
Abdomen:
Solid organs: The solid organ of the abdomen
are very susceptible to direct injury as well as
injury from the shock wave.
Injuries include direct and shock wave
damage to all of the solid organs such as the
liver, spleen, pancreas, and the kidneys in the
retroperitoneal space. Let’s not forget about
the bladder, uterus, ovaries, gall bladder, and
major blood vessels such as the vena cava and
the aorta.
Penetrating Trauma Injuries
Abdomen:
Bones: The pelvis is a very vascular organ.
Fracture of the pelvic due to a gunshot wound
can lead to major blood loss
Injuries are generally limited to direct bullet
track damage. The bone fragments may
become secondary missiles and cause
additional damage.
Shotgun Wounds
The ultimate in fragmentation is created by
shotgun wounds
Penetrating Trauma Injuries
Muscles, peripheral nerves and blood
vessels, connective tissue, skin and
bones:
All of these tissues may suffer direct
injury or shock wave injuries.
Injuries may include: tissue loss, bleeding,
and loss of function,
Open Wound
Rapid Trauma
Assessment
Rapid Trauma Assessment
Head
Neck
Chest
Abdomen
Pelvis
Extremities
Posterior
Inspect and Palpate for
DCAP-BTLS
D
C
A
P
=
=
=
=
Deformities
Contusions
Abrasions
Punctures/
Penetrations
B
T
L
S
=
=
=
=
Burns
Tenderness
Lacerations
Swelling
Significant Mechanism
of Injury
Assess baseline vital signs.
Obtain SAMPLE history.
Consider requesting ALS.
Reconsider transport decision.
SAMPLE History
S
= Signs and symptoms
A
= Allergies
M
= Medications
P
L
= Pertinent past history
= Last oral intake
E
= Events leading to injury
or illness
If No Significant Mechanism
of Injury
Reconsider mechanism of injury.
Determine chief complaint.
Perform focused physical exam
based on:
Chief complaint
Mechanism of injury
Detailed Physical
Exam
Who Needs a Detailed
Physical Exam?
Determined by patient’s condition:
After critical interventions for a
patient with significant MOI
Occasionally for a patient with no
significant MOI
Rarely for a medical patient
Who Needs a Detailed
Physical Exam?
You may never have time to
perform a detailed exam on a
patient with critical injuries.
Steps in the
Detailed
Physical Exam
The Detailed Physical Exam
Head
Neck
Chest
Assess areas
examined in rapid
trauma assessment
plus:
Abdomen
Face
Pelvis
Ears
Extremities
Eyes
Posterior
Nose
Mouth
The Detailed Physical Exam
Examine slower than during rapid
trauma assessment.
Often done during transport.
Reassess vital signs.
Bleeding
and Shock
External
Bleeding
Severity of Blood Loss
Determined by:
General impression of blood loss
Signs or symptoms of
hypoperfusion
Sudden loss of...
One liter of blood in an adult
Half a liter of blood in a child
100-200cc of blood in an infant
...is serious!
Blood Loss
Uncontrolled bleeding or
significant blood loss leads to
shock (hypoperfusion) and
possibly death!
Do not wait for signs and
symptoms to appear before
beginning treatment!
Internal Bleeding
Signs & Symptoms
of Internal Bleeding
Significant MOI
Pain, tenderness, deformity, swelling,
discoloration
Bleeding from the mouth, rectum, or
vagina
Tender, rigid, or distended abdomen
Maintain airway; administer oxygen.
Control external
bleeding.
Elevate lower extremities 8-12 inches.
Prevent loss of
body heat.
Transport immediately.
Transport to nearest Trauma facility, using
the most expeditious means available.
Documentation
Documentation
Document scene on arrival
Document any evidence noted on
scene
Document interaction with Law
Enforcement, Coroner, or Medical
Examiner
Questions ??
Post-Test
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1.
When arriving at a potential crime scene, the EMT should:
A. Leave all the vehicle emergency lights and siren on until
your reach the exact location of the call to announce your arrival
B. Park directly in front of the address given so you can be
easily seen
C. Wait for law enforcement officers to arrive before entering
the scene
D. All of the above
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3. You evaluate specific areas of the body during a rapid trauma
assessment to identify:
A. The greatest life-threats to the patient
B. All sites of bleeding
C. All fracture sites
D. Any threat that will require surgical intervention
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If a patient is in shock, you would expect the skin to be:
A. Cool and clammy
C.
Hot and dry
B. Warm and dry
D.
Warm and moist
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4.
The “Golden Hour” is a standard parameter for emergency care. The
severely injured patient has the best chance for survival if:
•
A. The patient arrives at the emergency department within one hour
of the injury
B. Surgical intervention takes place within one hour of the injury
C. Surgical intervention takes place within one hour after the patient’s
arrival at the hospital
D. The ambulance arrives at the scene within one hour of the injury
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5.
External bleeding that is rapid, spurting with each heartbeat, and
profuse is from a (n):
A. Artery
C. Capillary
B. Vein
D. All of the above
6.
When should you assess the scene of an accident or injury:
A. Only at the beginning of the call
B. At the beginning and throughout the entire call
C. Only when needed
D. After the patient has been treated for life threatening injuries
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7.
Calls to bar-rooms present the EMT with special challenges, including:
A. Alcohol-intoxicated people making the situation unpredictable
B. Friendships or feuds which may result in the further eruption of
violence
C. The dark atmosphere of the room especially if the EMT comes in
from bright sunlight
D. All of the above
8.
A 16-year-old female patient received a gunshot wound to her
abdomen. You should inspect and palpate her posterior region for:
A. Vein distention
C. Tenderness to the spine
B. Paradoxical motion
D. Muscular spasms
9.
Body substance isolation (BSI) precautions that should be taken when
there is a possibility of blood spatter include:
A. Gloves
C. Masks
B. Protective eyewear
D. All of the above
10. As you monitor the patient that you believe is going into shock, one of
the last signs you should expect to see is:
A. An increased pulse rate
C. Increased respirations
B. Decreased blood pressure
D. Cool, clammy, pale skin
Contact Information
Renee Anderson
[email protected]
509-232-8155