Gunshot wounds

Richard P. Kness, EMT- P

Warning: This presentation has extremely graphic pictures!

ObjectivesAfter 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 high-velocity weapons

SceneSize-Up

Overall Assessment Scheme

Scene Size-Up

Initial Assessment

Trauma

Physical Exam

Vital Signs &SAMPLE History

DetailedPhysical Exam

OngoingAssessment

HOSP

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

Use scene clues:

Fighting

Loud voices

Alcohol/drug use

Unusual silence

Prior experience

Scene Violence

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?

BodySubstanceIsolation

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 SchemeScene Size-Up

Initial Assessment

Trauma

Physical Exam

Vital Signs &SAMPLE History

DetailedPhysical Exam

OngoingAssessment

HOSP

Assessing the Trauma Patient

Is there a significant mechanism of injury?

NoPerform a focused

assessment.

YesPerform a rapid

assessment.

Mechanism of Injury

Mechanism of InjuryMechanism of Injury

Gunshot wounds

Mechanism of Injury

The physical event that caused an injury (knife wound, gun shot wound, motor vehicle accident, etc.)

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

Mechanism of Injury: Penetrating Trauma

Wound ballistics(Kinematics)

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.

Wound Ballistics: Medium and High velocity wounds

To what is cavitation (shock wave) related?

Gunshot Wounds: Cavitation

Entrance and exit wounds

Gunshot 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.

Wound Ballistics: Medium and High velocity wounds

Entrance and Exit Wounds

The wound consists of three parts:

Internal wound: Medium-velocity bullets inflict damage primarily by damaging tissue that the bullet contacts; High-velocity bullets inflict damage by tissue contact and transfer of kinetic energy (the shock wave producing a temporary cavity) to surrounding tissues

Wound Ballistics: Medium and High velocity wounds

Mechanism of Injury: Penetrating Trauma

Gunshot wound 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

Penetrating Trauma Injuries

Punctures/Penetrations (Gunshot wounds)

Punctures/Penetrations (Gunshot wounds)

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.

Penetrating Trauma Injuries

Punctures/Penetrations (Gunshot wounds)

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.

Penetrating Trauma Injuries

The ultimate in fragmentation is created by shotgun wounds

Shotgun Wounds

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,

Penetrating Trauma Injuries

Open Wound

Rapid TraumaAssessment

Rapid Trauma AssessmentHead

Neck

Chest

Abdomen

Pelvis

Extremities

Posterior

Inspect and Palpate forDCAP-BTLS

====

DCAP

DeformitiesContusionsAbrasionsPunctures/Penetrations

====

BTLS

BurnsTendernessLacerationsSwelling

Assess baseline vital signs.

Obtain SAMPLE history.

Consider requesting ALS.

Reconsider transport decision.

Significant Mechanism of Injury

SAMPLE History

S = Signs and symptoms

A = Allergies

M = Medications

P = Pertinent past history

L = Last oral intake

E = Events leading to injury or illness

If No Significant Mechanismof 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 DetailedPhysical 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

You may never have time to perform a detailed exam on a patient with critical injuries.

Who Needs a DetailedPhysical Exam?

Steps in theDetailed

Physical Exam

The Detailed Physical Exam

Assess areas examined in rapid trauma assessment plus:

Face

Ears

Eyes

Nose

Mouth

Head

Neck

Chest

Abdomen

Pelvis

Extremities

Posterior

Examine slower than during rapid trauma assessment.

Often done during transport.

Reassess vital signs.

The Detailed Physical Exam

Bleeding and Shock

ExternalBleeding

Severity of Blood LossDetermined 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!

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!

Blood Loss

Internal Bleeding

Signs & Symptomsof 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• 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

• 2. 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

• 3. You evaluate specific areas of the body during a rapid trauma assessment to identify:

• A. The greatest life-threats to the patientB. All sites of bleeding

• C. All fracture sites• D. Any threat that will require surgical intervention

• 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

• 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

• 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 rateC. Increased respirations• B. Decreased blood pressure D. Cool, clammy, pale skin

Contact Information

Renee Anderson

andersr@inhs.org

509-232-8155