# cpr with bullet wound



## tennisaceflink

I just saw in a movie that they were doing CPR on someone with two bullet wounds to the chest, with no occlusive dressing over the wounds.  One would think that if you were doing cpr you are pumping blood for them and since there is an open wounds the blood would just be pumped out of the body.  I am a new EMT so i apologize if this question is dumb. Just got my emt card the other day lol


----------



## bigbaldguy

tennisaceflink said:


> I just saw in a movie that they were doing CPR on someone with two bullet wounds to the chest, with no occlusive dressing over the wounds.  One would think that if you were doing cpr you are pumping blood for them and since there is an open wounds the blood would just be pumped out of the body.  I am a new EMT so i apologize if this question is dumb. Just got my emt card the other day lol



No pulses start CPR. Patch holes later. Even if you patched external holes there will be internal bleeding you can do nothing about. 

Remember your priorities.  CAB or ABC


----------



## errey

I agree going by our protocols in Canada you start cpr its better to get the blood circulating right away rather than wait to patch.  you could have a partner put a gloved hand over the wounds until you are able to patch if possible


----------



## bigbaldguy

Remember that an arrest is always an arrest and your main priority is saving the brain. To save the brain you need to get blood flowing. That said in this situation you wouldn't stay on scene and work the arrest obviously. Your main priority would be to get the guy to a trauma center ASAP.

Ok other than rapid fluid/blood product infusion why would you want to do your best to get two large bore IVs started on this guy as soon as possible?

First correct answer gets a patch


----------



## firetender

As for your question, yes, I have had a multiple gun shot victim who went South on me, I began CPR and blood didn't exactly spurt out of the holes but it didn't ooze, either. More like bubbled without the air. Yup, I was fascinated; "Gee, it really works!"


----------



## RocketMedic

Remember that traumatic arrest is almost always death. The best possible way you _might_ make a difference is identifying a cause of arrest and treating that- in this case, your most likely three are hypovolemia from massive hemorrhaging, structural destruction, and pneumothorax. On a BLS level, we can seal the chest and do CPR, but that's a lot like rearranging deck chairs on the Titanic. On an ALS level, you can dart the chest (which may help) and infuse IV fluid (probably won't matter).

The most important thing you can do is manage your patient effectively and look for an H/T- you might get lucky. CPR is a holding measure.


----------



## Veneficus

Rocketmedic40 said:


> On a BLS level, we can seal the chest and do CPR, but that's a lot like rearranging deck chairs on the Titanic.



This is just a great phrase.


----------



## RocketMedic

Thank you.


----------



## ExpatMedic0

Pretty rare to even work a traumatic arrest. In my experience its only if they code after I have made patient contact.


----------



## Bullets

Multiple gunshot wounds to the chest...injuries incompatible with life probably wouldnt work it in the first place


----------



## NYMedic828

Consider the viability of this patient. 

EMS protocol tells us to work the patient up. Realistically, get on the phone and get a pronouncement. 

The cause of death is physical damage to body structures and or loss of substantial amounts of blood/heme. You won't fix this patient. A surgeon won't fix this patient. Jesus can't fix this patient.

Pronounce.


----------



## bigbaldguy

Bullets said:


> Multiple gunshot wounds to the chest...injuries incompatible with life probably wouldnt work it in the first place



Gunshot wounds to the chest are injuries incompatible with life? What are we assuming he was shot with a cannon.


----------



## bigbaldguy

Excellent video discussing gun shot wounds by an MD. Warning very graphic. Please ignore the dorky guy in the first 3 minutes.

[youtube]tku8YI68-JA[/youtube]


----------



## NYMedic828

bigbaldguy said:


> Gunshot wounds to the chest are injuries incompatible with life? What are we assuming he was shot with a cannon.



Gunshot wounds to the chest resulting in cardiac arrest are pretty incompatible with life to me.

How do you or anyone else plan to fix this patient? I don't know of a single person that has taken a patient in traumatic arrest to the hospital and had them survive. Actually I don't know of any traumatic arrest anywhere that has been revived. I'm sure its happened, but to a full life with mental capacity, I highly doubt it.

If a patient has suffered exsanguinating blood loss to the point of extremis no amount of chest compressions, saline and ventilations is going to bring them back. 

I had a patient shot DIRECTLY in the heart. I had to transport him and perform CPR. Had the patient had textbook anatomy, the shot would of perfectly transected the heart. Absolutely ridiculous. But these are the patients we expect to save and our medical directors apparently believe it too.

A patient in traumatic arrest is not going to arrive in the ER, immediately go to surgery and be miraculously revived. Maybe if Vene was the surgeon but otherwise...come on...

Also, money is an issue. What physician in their right mind is going to send a patient in traumatic arrest to surgery?

There is a reason its called irreversible shock...


----------



## bigbaldguy

NYMedic828 said:


> Gunshot wounds to the chest resulting in cardiac arrest are pretty incompatible with life to me.
> 
> How do you or anyone else plan to fix this patient? I don't know of a single person that has taken a patient in traumatic arrest to the hospital and had them survive. Actually I don't know of any traumatic arrest anywhere that has been revived. I'm sure its happened, but to a full life with mental capacity, I highly doubt it.
> 
> If a patient has suffered exsanguinating blood loss to the point of extremis no amount of chest compressions, saline and ventilations is going to bring them back.
> 
> I had a patient shot DIRECTLY in the heart. I had to transport him and perform CPR. Had the patient had textbook anatomy, the shot would of perfectly transected the heart. Absolutely ridiculous. But these are the patients we expect to save and our medical directors apparently believe it too.
> 
> A patient in traumatic arrest is not going to arrive in the ER, immediately go to surgery and be miraculously revived. Maybe if Vene was the surgeon but otherwise...come on...
> 
> Also, money is an issue. What physician in their right mind is going to send a patient in traumatic arrest to surgery?
> 
> There is a reason its called irreversible shock...



So just to be clear if you find a guy on the sidewalk with two bullet holes in his chest no pulse you're not going to work him?


----------



## bigbaldguy

Found this article that seems to agree with you Nymedic. I stand corrected. 

https://secure.muhealth.org/~ed/students/articles/annem_48_p0240.pdf


Out of 900 patients only 48 survived to discharge.


----------



## Medic Tim

bigbaldguy said:


> So just to be clear if you find a guy on the sidewalk with two bullet holes in his chest no pulse you're not going to work him?



Correct , though I am sure a lot of ppl I work with want would run it. Then again we are 15 min to  a smaller community hospital and an hour to the nearest  trauma center which is only a level 3 (not sure how it translates to the us trauma system)


----------



## ExpatMedic0

why in the world would you work a trauma DOA?


----------



## Martyn

bigbaldguy said:


> Ok other than rapid fluid/blood product infusion why would you want to do your best to get two large bore IVs started on this guy as soon as possible?
> 
> First correct answer gets a patch


 
As the loss of blood increases the BP rises then falls, as the BP falls the veins/arteries shrink making it harder to get a stick


----------



## NYMedic828

bigbaldguy said:


> So just to be clear if you find a guy on the sidewalk with two bullet holes in his chest no pulse you're not going to work him?



In NYC I'm required to work him. But I will probably get on the phone and ask for a pronouncement instead of transport.

Why disturb the crime scene for no reason? Granted it isn't an immediately mortal injury but if it was bad enough to take a man's life, it isn't going to be fixed.


----------



## bigbaldguy

NYMedic828 said:


> In NYC I'm required to work him. But I will probably get on the phone and ask for a pronouncement instead of transport.
> 
> Why disturb the crime scene for no reason? Granted it isn't an immediately mortal injury but if it was bad enough to take a man's life, it isn't going to be fixed.



Ok just checking. Perhaps because my town has 3 level 1 trauma centers my thinking is a bit different. 

I did some research though and you are correct that in the majority of systems traumatic arrests generally are pronounced not worked. 

Out of hospital cardiac arrest overall survival rates when transported by ambulance is 14 percent.

Traumatic arrest overall survival rate is 8 percent when transported by ambulance. 

I guess the major difference is with Trauma you need a trauma center but any hospital can work a non traumatic code?


----------



## bigbaldguy

Martyn said:


> As the loss of blood increases the BP rises then falls, as the BP falls the veins/arteries shrink making it harder to get a stick



Someone was paying attention. Nice work Martyn you've won an embroidered EMTLIFE patch.


----------



## VFlutter

NYMedic828 said:


> How do you or anyone else plan to fix this patient? I don't know of a single person that has taken a patient in traumatic arrest to the hospital and had them survive. Actually I don't know of any traumatic arrest anywhere that has been revived. I'm sure its happened, but to a full life with mental capacity, I highly doubt it..



London HEMS doctors do a thoracotomy on scene for penetrating traumatic arrests (mostly stabbings). I believe they have a decent success rate (given the odds)

But in the USA.....no chance


----------



## Veneficus

bigbaldguy said:


> I guess the major difference is with Trauma you need a trauma center but any hospital can work a non traumatic code?



There are a couple of factors that come into play.

Trauma centers are generally in urban areas, where volume wise, there is more trauma with a very short transport time.

Another factor that comes into play is the surgery/ICU avaliability. Most trauma does not require surgery, but high acuity requires a $hitload of resources and experience quickly.

Perhaps the most major aspect is that medical arrests usually originate from one system. So if you can bring that system back to a compensatory level of function, you are likely to get a save. (like reversing v-fib in acute MI) 

In trauma, every system in the body is affected with multiple organs and systems suddenly decompensating. 

Most outside of critical medicine/surgery, are never taught that death from shock occurs in 2 phases. 1. failure of o2 delivery 2.inflammatory response.
Even most emergency rooms only deal with oxygen delivery. So just like the MI example, one pathology involved is much easier to deal with.

Restoring delivery of oxygen may require immediate surgery, many ERs are not equipped for it nor providers prepared to do it. 

While many EMs will argue that they can open a chest and certainly I do not dispute that, how many actually do?

How many are prepared/willing to open another part of the body like the abdomen, shoulder, skull, or neck to correct vascular trauma?

How many will create a temporary graft or shunt?

Even when you get this O2 delivery fixed, the subsequent inflammatory response is very difficult to manage and the patient will likely die in the ICU. In a very scripted and predictable way. After a few observations, you can actually see the pattern.

Critical trauma is a game where the board it already set against you. It is like starting a chess game where you don't get many of your good pieces and are already in check. Trauma arrests are even worse.


----------



## Brandon O

bigbaldguy said:


> Traumatic arrest overall survival rate is 8 percent when transported by ambulance.



I've never ever seen a figure for overall survival from traumatic arrest that high. What system is generating 8%? Most places, the number is well under 1%.


----------



## Veneficus

Brandon Oto said:


> I've never ever seen a figure for overall survival from traumatic arrest that high. What system is generating 8%? Most places, the number is well under 1%.



I have seen US stats that seperate blunt traumatic arrest from penetrating at <0.05 and 6% respectively. 

I have never seen a specific criteria for classifying traumatic arrest, some centers count witnessed traumatic arrest, some count unwitnessed, world wide, some systems such as Israel and England have physician field responders, with advanced equipment. 

A penetrating arrest survival at 8% I would just chalk up to local variation.


----------



## bigbaldguy

Brandon Oto said:


> I've never ever seen a figure for overall survival from traumatic arrest that high. What system is generating 8%? Most places, the number is well under 1%.



Study I looked at did say blunt was much lower, less than 1% I believe it was a study using medics in London. Give me a few and I'll dig up link.

Link to study I sited should have included it to begin with sorry. London was study area and I believe it was physician lead system. Not sure if that means a physician was on truck or not. Also I'm not sure if that was excluding blunt trauma or including it. 

https://secure.muhealth.org/~ed/students/articles/annem_48_p0240.pdf


----------



## bigbaldguy

After rereading the study im back to thinking dismissing all traumatic arrests as being not worth working is a bit overreaching. Admittedly this is a small study of only one service with a physician present. It does look like the odds are incredibly stacked against them but most traumatic arrests are young adults who I would think have better chances of long term survival if you can get ROSC. 

It just seems weird to me that medics will work a 90 year old for 20 minutes but an 18 year old who might actually have a few brain cells left are written off as a lost cause.


----------



## ExpatMedic0

Brandon Oto said:


> I've never ever seen a figure for overall survival from traumatic arrest that high. What system is generating 8%? Most places, the number is well under 1%.



Agreed. Ill site some sources later if no one else can dig some up. Every system I have worked in we can call them DOA ourselves or call the doc to confirm for DOA.


----------



## Brandon O

bigbaldguy said:


> Study I looked at did say blunt was much lower, less than 1% I believe it was a study using medics in London. Give me a few and I'll dig up link.
> 
> Link to study I sited should have included it to begin with sorry. London was study area and I believe it was physician lead system. Not sure if that means a physician was on truck or not. Also I'm not sure if that was excluding blunt trauma or including it.
> 
> https://secure.muhealth.org/~ed/students/articles/annem_48_p0240.pdf



Thanks. That makes much more sense. If you exclude those which were truly medical arrests, tension pneumos, and secondary hypoxic arrests, we're back at around 2% survival, which is still pretty good but much more in line with other data.

We are still taught to look for correctable causes (H&Ts), or for an underlying medical etiology, and in many areas to view penetrating trauma with short transport times as a potentially salvageable subclass; so I think these points should not be too surprising.


----------



## NYMedic828

The reason we do CPR on a 90 year old with heart failure over an 18 year old with 4 bullets in his upper chest is strongly based on ethics and the expectation of society.

Most people are pretty in line with 4 bullets to the chest being the end of the line. When their grandmother goes into asystole, they assume there is still hope. 

From a more proffesional medical standpoint, it is equally ridiculius and a wasted effort.


----------



## Tigger

NYMedic828 said:


> The reason we do CPR on a 90 year old with heart failure over an 18 year old with 4 bullets in his upper chest is strongly based on ethics and the expectation of society.
> 
> Most people are pretty in line with 4 bullets to the chest being the end of the line. When their grandmother goes into asystole, they assume there is still hope.
> 
> From a more proffesional medical standpoint, it is equally ridiculius and a wasted effort.



4 bullets in the chest that have done their job and created massive multi system organ damage also starts to flirt with the idea of "injuries incompatible with life..."


----------



## Veneficus

Tigger said:


> 4 bullets in the chest that have done their job and created massive multi system organ damage also starts to flirt with the idea of "injuries incompatible with life..."



I would say it depends on where in the chest and the trajectory. 

One side shot in the thorax and it is likely over. 

I actually have a picture of a patient with 5 bullet wounds in his chest and abdomen sitting up in the trauma bay because he said it was easier to breath than laying flat.


----------



## bigbaldguy

NYMedic828 said:


> The reason we do CPR on a 90 year old with heart failure over an 18 year old with 4 bullets in his upper chest is strongly based on ethics and the expectation of society.
> 
> Most people are pretty in line with 4 bullets to the chest being the end of the line. When their grandmother goes into asystole, they assume there is still hope.
> 
> From a more proffesional medical standpoint, it is equally ridiculius and a wasted effort.



I'm a bit more synical perhaps. I think it has very little to do with ethics and much more to do with old folks having Medicare/insurance. If gang bangers carried health insurance I suspect there would be more emphasis on working them


----------



## NYMedic828

bigbaldguy said:


> I'm a bit more synical perhaps. I think it has very little to do with ethics and much more to do with old folks having Medicare/insurance. If gang bangers carried health insurance I suspect there would be more emphasis on working them



Just about every unemployment non-contributing gang banger in NYC carries a Medicaid card. Fortunately for us, that's only 95% of the population here.


----------



## Brandon O

bigbaldguy said:


> I'm a bit more synical perhaps. I think it has very little to do with ethics and much more to do with old folks having Medicare/insurance. If gang bangers carried health insurance I suspect there would be more emphasis on working them



I've seen a lot of questionable motivations in providers, but I have yet to see anyone restrict their treatment based on the patient's ability to pay -- unless it's for the patient's benefit.


----------



## bigbaldguy

Brandon Oto said:


> I've seen a lot of questionable motivations in providers, but I have yet to see anyone restrict their treatment based on the patient's ability to pay -- unless it's for the patient's benefit.



I'm not saying providers withhold treatment for this reason. I'm saying that the people who create the guidelines which trickle down decide who does and doesn't get care and to what extent.

As I understand it medicaid doesn't pay what Medicare does for similar services but I have little experience with Medicare and almost none with Medicaid. I would be interested to see a side by side comparison of reimbursements for similar treatments though.


----------



## Brandon O

bigbaldguy said:


> I'm not saying providers withhold treatment for this reason. I'm saying that the people who create the guidelines which trickle down decide who does and doesn't get care and to what extent.



I truly don't think so. In no system I've seen are the people who look after the money the same people who establish protocols. The latter are almost always MDs -- clinicians -- and although you can disagree with the decisions they make, it's tough to make the case that they're not trying to help the patients. If you do think there are evil Scrooge McDocs out there twirling their moustaches, name some names and we'll see.

Even if there were, protocols like witholding resuscitation are so charged that you really can't even have an appearance of impropriety or injudiciousness. All it takes is one family member on the steps of the courthouse asking why you sentenced their son to death and the jig is up.

I have no doubt that there are people in this game, particularly in private EMS, who only care about the money. Some of them may even twirl their moustaches. But it's not the clinicians. Even if they _were_ the type, they're never the ones who stand to benefit anyway; the money doesn't go to them.


----------



## NYMedic828

I'm not sure NYC even bills for cardiac arrests...

Who are you going to go after for the money if they have no family.


----------

