By Dr. Nic Sparrow MBBS, BSc, MRCGP

Medical Director – Pre-Hospital Care Worldwww.phcworld.org

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

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)

Pre-Hospital Care (PHC) Provider

Airway Breathing Circulation Disability Exposure

Assessment is often done simultaneouslyAlways 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 ?

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 Useful Piece of Pre-Hospital Equipment:

- The CAT tourniquet can be used to control massive haemorrhagic loss in

stabbed or shot patients

PHC PROVIDER

•SECURE THE C-SPINE

INSPECT FOR:-

•FOREIGN BODIES •FACIAL / MANDIBULAR #’S•TRACHEAL / LARYNGEAL #’S•EXPANDING HAEMATOMAS

ALL CAN LEAD TO AIRWAY OBSTRUCTION AND DEATH

Consider the risks of Air Embolus in vascular injuries to the neck

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:-

1. Oxygen 15L (Reservoir Bag)2. Oropharyngeal airway3. Nasopharyngeal airway4. Extraglottic Devices5. Endotracheal intubation 6. Emergency Cricothyroidotomy

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.

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

PHC Provider

Inspection – Tracheal position, distended neck veins, chest movement, respiratory rate

Auscultation – Air entry, breath sounds, vocal fremitus

Percussion – Dull / hyperesonant

Measure – Respiratory rate & O2 saturations

Life threatening conditions include:- ( ATOMIC – TAO )

Airway obstruction

Tension pneumothorax

Open pneumothorax

Massive Haemothorax

Instability of chest wall (flail Chest & contusions)

Cardiac Tamponade

Tracheal or Bronchial Injury

Aortic / Oesophageal Rupture

‘Posterior stab wound – what might you expect to see on x-ray ? ’

Right Sided Pneumothorax

Consider other possible Structures Injured e.g. oesophagus

Large Right Haemothorax

Haemorrhage is the predominant cause of preventable post-injury deaths. 90% of shock is haemorrhagic in trauma

↓ GCS can be caused by ↓ cerebral perfusion secondary to haemorrhagic shock

Important to consider all possible injuries to organs or vessels in penetrating trauma

Observation – inspect the scene and estimate blood loss, assess colour / temperature of the patient

Palpation – feel for peripheral pulses / strength, character and rate

Auscultation – heart sounds ? muffled

Check Manual Blood pressure on non-injured side

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 be required in the profoundly shocked patient

FLUID RESUSCITATION:

STAGE 1

X2 RINGERS LACTATEMAX (2000 ML)

STAGE 2

X4 GELOFUSINMAX (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)

DISABILITY

AVPU Scoring Assess the GCS Pupils Neurological Deficit

EXPOSURE

Remove clothing (save for forensics)