GSW hypotension/brady

Brandon O

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Even with a small entrance wound and no visible external hemorrhage there is a pretty good likelihood of injury to major vasculature. "Zone 2" injuries have the highest incidence of carotid and vertebral artery injury. When in doubt, pack it
Although hard to say over the internet, this sounds like a zone 1 injury. Can try to pack (no delaying!) but it may be tricky.
 

StCEMT

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@Brandon O 30 I would definitely call inappropriate, but he didnt start that way, that was a sudden change. Time wasn't an issue. 23 minutes from dispatch, stage, extrication from back of house, treat, transport a couple miles. Had a beautiful 14, so I had good access and everything standing by. All your main concerns were addresses as needed, this is simply to discuss a hypothetical what if considering the treatment option and the conflicting possible injuries.

No, definitely a Zone II injury.

@VFlutter, interesting. This was just shy of halfway up zone II if I had to ballpark it.
 

VFlutter

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Although hard to say over the internet, this sounds like a zone 1 injury. Can try to pack (no delaying!) but it may be tricky.
Either way, penetrating trauma with suspected non-compressible hemorrhage gets packed. Preferably with hemostatic gauze. Obviously do not delay transport but something to do on the way.
 

CALEMT

The Other Guy/ Paramaybe?
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Estimated caliber?
 

Akulahawk

EMT-P/ED RN
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E tank

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It's not much different from penetrating trauma to the abdomen that's crashing in front of you. For whatever reason people sometimes want to do everything but surgery. Must be neurogenic, or inflammatory, or the cuff is wrong... it's like the guy in the horror movie who says "it's just the wind." The occasional negative laparotomy is not the end of the world, but watching someone code in the trauma bay while people push epi and do the no-surgery dance is quite poor form.
I'm not sure where the controversy is...The original post was by a pre-hospital provider so my response is in the context of pre-hospital care...conflating hemodynamic support on the way to the hospital with elaborate zebra chasing in the trauma bay makes no sense at all. You state the obvious...am I missing something?
 

StCEMT

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I kinda figured just based on the location of the wound. I guess call it curiosity.
Hell if I know. I just assume 9mm because it's common. We found him in the very back of the house, I don't even know where he was actually shot.
 

VFlutter

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Another good tip for penetrating neck wounds if you do not want to pack it. Pressure dressing using an ace bandage. Can do a similar style bandage around the hip for Junctional/groin injuries

 

Peak

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Transport time is huge, so in the back of he bus I would stick to just basic meds. This is a patient who certainly needs rapid surgical exploration/repair.

If there isn't a change in mental status then a HR of 30 may be fine, but really over simplified your CI is going to be a fraction of most trauma patients when your rate is 1/3 to 1/4 of what most adult trauma present with (of course this is not considering any other hemodynamics). Even with a good BP if a patient's SV is even mildly decreased due to poor preload and is at 50 you are looking at a CI of 1.5 (even a normal SV of 70 is only going to get a CI of 2.1).

It's great that you got a 14, if the patient was difficult to access I agree with others that an IO is a great option. Based on your presentation this does sound to have a neuro component, although that certainly does not preclude vascular or airway injury to the neck/chest (for example I wouldn't exclude something like a tension hemo/pneumo in the mediastinum). I would probably have given 1 mg of atropine, I know that atropine has fallen out of favor but the risks are pretty low and shouldn't significantly raise BP in the trauma patient who has a good pressure (I understand that BP in this case probably has room for improvement). If the patient is hypotensive than PD Epi of 10 mcg q1min titrated up to 50mcg/push could be a reasonable temporizing measure.

I wonder if there is a good benefit of dosing the patient with Dex if there is a spinal cord swelling component, but most of my experience with this has been from essentially isolated spinal injuries without other trauma (kids diving in the poll and people falling off horses). I'm not sure how the risks would play out with the rest of their trauma care.
 

bigbaldguy

Former medic seven years 911 service in houston
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Sorry, backing up to packing the wound. Is it possible to pack a 9mm entry wound without risking further injury in this scenario. I've only seen one comparable wound in a calf (police issue 9mm). Exit wound could have been packed but entrance wound was very small.
 

Peak

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I had a guy that got shot with a 38 SWC recently in the subclavian (didn't know size or his actual pathology at the time) and I could have gotten 1/4" in it, but we just put a chest seal on it since we were transporting emergent and we needed him in the OR.

I did know a guy who had a patient with a lacerated IJ and common carotid who just stuck his fingers and held pressure until they got him to the OR, I doubt many protocols these days would support that.
 

StCEMT

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@Peak I was wondering about atropine as well. I think my slight lean towards epi was simply due to the risk of spinal injury. We got no movement below the neck from him. Didn't speak, didn't flinch at the 14, didn't move when I tried to reflex test his foot. Just blinked on command. I'll leave the Dex stuff to our anesthesia dudes, that's above my pay grade. I have it, but I tend to average about 22 minutes on these types of shootings from dispatch to hospital, so my window and ability to do it is pretty small unless I am lucky to have an extra medic floating around.
 

Brandon O

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I wonder if there is a good benefit of dosing the patient with Dex if there is a spinal cord swelling
No, but they still might.
 

StCEMT

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Going to get in touch with our liason and see if I can snag the scans and results of the surgery. Give me a few days to try to provide an official update.
 

VFlutter

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Sorry, backing up to packing the wound. Is it possible to pack a 9mm entry wound without risking further injury in this scenario. I've only seen one comparable wound in a calf (police issue 9mm). Exit wound could have been packed but entrance wound was very small.
IMO if you can put your finger in it, you can pack it. Pack until resistance is met. There may be a risk of damage but probably less of a risk than bleeding to death from already damaged vessels.

I'm not an expert but the few penetrating neck wounds I have seen were packed immediately in ER (which happens to have a lot of military MDs). I'm sure some of our military dudes on here may have more insight.
 

ParamagicFF

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I deal with GSWs quite frequently. I can't say I've had extensive trauma training, but the general consensus I've gathered from thoughtful discussion with trauma docs and surgeons has been "if you can't tourniquet, then pack".
I've had success in packing quite small entrance wounds. One midline between the quad and the hamstring. Rapid blood loss, tachycardia. I could barely fit my pinky in to press the gauze in. Packed until firm resistance was met and held pressure to the trauma bay. I arrived and the trauma bay and the MD ordered an RN to remove the gauze at which point the bleeding starts again. He instructs her to try to plug the vessel with her "small fingers" while he steps up surgery.
I asked why he removed the packing and if it was inappropriate, and he said that it was done properly, and more often than not he sees people bring in wounds that arent truly packed. Providers are too afraid of secondary injury. From then on I've tried to remain aggressive with packing during transport.
 

StCEMT

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So partial update, the reason the wound didn't bleed a lot when I saw it was because he took care of the bleeding part prior to my arrival...the scene wasn't bad, so I assume some for of point A to point B happened. It started leaking again when blood was transfused, they did a thoracotomy, cross clamped the aorta, and some other MD level voodoo before the OR. Doc (not a treating one, just standing next to me watching) said he absolutely would have been a good one to pack, but since it wasn't actively bleeding it probably wouldn't have saved much. That and a collar is kind of irrelevant at that point since any damage is done. Pack+pressure > collar was my take away. Stil a good learning point. Now just working on a detailed follow up, I forgolet what artery was hit and he didn't know about spinal injury.
 

Brandon O

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It started leaking again when blood was transfused
That'll happen. Some folks won't get a pulse back unless you can stick in a finger or something to occlude their bleeder.
 

VFlutter

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Aortic cross clamp isn't necessarily a bad idea if he is peri-arrest but doesn't really help for the actual injury since the major neck vessels are still perfused.
 
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