Gun Shot Wound

[traumateam1]

Right now this seems to be a fairly hot topic in the BLS section. There is a lot of oppinions as to what people would do, so I decided to make this into a scenario to see what people would do.
(All the vitals, symptoms, etc do not reflect the patients actual vitals, symptoms, etc in the BLS scenario)

At about 23:00 the radio silence is finally broken.
Dispatch: 29 Alpha respond code 3 to the the corner of Main St and Westminster Ave. Police reporting one male shot in back.
Your Partner: 10-4 dispatch, 29 Alpha responding code 3 to location.. please advise police do have scene secure?
Dispatch: 10-4 Alpha, police do have scene secure.

After a short 6 minute drive you show up on scene and get your gear, before a police office directs you to the patient. This is where to your surprise you find a 27 y/o male sitting on the the edge of the side walk with no blood showing from the front of your patient.
You introduce yourself and your partner and start assessing him.
Alright, here is where you guys take over. Whatever you want to know I will tell you. If you don't say you did it (i.e cut off shirt) then lets you didn't do it. Just like training eh.

Have fun! h34r:

 

[fma08]

RABC- does he respond to you?? talk hopefully... so airway? Breathing rate and quality, any major bleeding noted? talk to him... ask him what happened and look for any gunshot wound. skin color, temp, condition, GCS? A&O x3? Anything to suggest there might be something compromising c-spine? (i'm gonna go ahead and guess the wound is in the back near the spine, but i'll let you tell me for sure )

 

[Chiron]

I would echo fma08's questions. I would be looking to form a general impression of the Pt. as I approach.

When he is addressed does he reply? Any major life threatening bleeds noted. Resp. rate, depth, quality and effort? Does he have a radial pulse? If not does he have a corrotid?

He is sitting up, but that could be a distractor, it dosn't necessarily mean he isn't fubar'd or headed in that direction.

I'll check back later for answers to the first step questions.

 

[traumateam1]

RABC- does he respond to you?? talk hopefully... so airway? Breathing rate and quality, any major bleeding noted? talk to him... ask him what happened and look for any gunshot wound. skin color, temp, condition, GCS? A&O x3? Anything to suggest there might be something compromising c-spine? (i'm gonna go ahead and guess the wound is in the back near the spine, but i'll let you tell me for sure )

A - Open, and Clear
B - It's about 24, equal and effective
C - There is a strong radial pulse. Skin is warm, sweaty, and a little flushed
As you assess his Back you find blood, further examination finds a single bullet wound near his spine
GCS -15. Patient is A&Ox3.
And on initial examination there is, at this point, nothing to suggest a C-Spine compromise.

 

[fma08]

so cut away the shirt, making sure not to cut through the bullet hole (gotta preserve that evidence ^_^ ) palpate around the area for any crepitis, listen to lung sounds, palpate the neck and spine. dress the wound. check CMS, lay him straight back on a long board, secure him down. check CMS again. i suppose looking for an exit wound would be a good thing too... AMPLE Hx, vitals and take off, IV w/ lock... unless he needs fluids, ECG, pain management if his vitals and HX allow.

 

[Chiron]

+1 fma08 on the exposure without cutting through the hole. Preserving life is always job 1 for us, but when treating the victims of violence preserving evidence should be one of our goals as well . To that end make sure that the clothing that is removed is placed in a clean paper bag rather than plastic, so that the bio evidence is not destroyed.

Any hoo.... Regaurding Pt. care.... Since the airway seems to be intact Bleeding control would be the point of main effort. I wouldn't be concerned with "c-spine" injury per'se if the wound was located in the lower back but a lower spinal injury could not be ruled out in the field, so immobilization would be indicated in a secure scene.

I wouldn't be thinking volume replacement at this point because pulses are strong and mentation is in tact, but I'd probably like to obtain IV access with a single 18ga cath set up with a lock enroute to the trauma center.

You said that motor sensory and perception is still intact, re-confirm, check for signs of deterioration and get this show on the road.

 

[Chiron]

Oh yah I forgot to ask, are you trying to steer us towards a presentation of spinal shock with the flushed skin info rather than pale skin (which would be the first organ to exhibit change in the conventional shock model).

 

[fma08]

good catch... i'll ask on top of that, where is the skin flushed? all over? or just a section of the body?

 

[traumateam1]

So after you have cut off that shirt, and not the bullet hole and assess for crepitis you feel or hear none.
Lung sounds are clear to basis
When you palpate the neck and spine ther is 0 pain noted, and nothing abnormal found at this time. CSM reveals nothing out of the ordinary before and then after being secured to the backboard.
When you look for an exit would you find none.
Your AMPLE exam reveals nothing more that is of concern, however he was running away from this "crazy" guy, when he was shot in the back. (Hence the flushed skin) also its about 25 C out still.

Sorry, I don't do ECG's.. but for you ALS guys when you hook it up you find him a little tachy but in regular sinus rhythm.
And your ETA to hospital is about 14 minutes code 3.

 

[fma08]

well then, like stated above, vitals, dress wound, board, get on the road, good size IV w/ lock (18g+). repeat initial assessment and vitals every 5, keeping close eye on lung sounds and CMS.

 

[Chiron]

Just a momentary side bar if I may.

I suggested the 18ga for a couple of reasons. Any self respecting medic would likely have a high success rate with the 18ga in a trauma because we start them all the time on medical calls. One good moderate sized line is better then two large bore lines that you miss. Secondly the 18ga is still large enough to push alot of fluid through if you had to.

As far as the scenario goes I'm with fma08, reassess enroute. Is there anything else that we need to address?

 

[traumateam1]

I agree with the 18ga comment, for the record lol...

And no, the guy makes it to the ER alive, and quickly into the OR.
I mainly did this, to see if people would backboard this GSW or not, becuase like I said in the BLS thread, there was a lot of talk about whether or not to backboard this type of patient.

Thanks guys! ^_^

 

[Chiron]

Understood.

I would always backboard a Pt with penetrating trauma to the torso where spinal involvement is suspected, that is when the tactical situation permits.

If for any reason we had an active threat or reason to believe that our current scene has become unsafe I would forgo the immobilization and move the crew and the victim to a position of cover immediately.

Think car accident v. car fire. We routinely immobilize Pt.s involved in car accidents with deceleration injuries and multi-system trauma. We would not attempt to provide the same treatment for a Pt. suffering from the same type of injury if the car were on fire.

Good scenario though. I've dealt with both kinds of Pt. in both kinds of scenes and your question did not at all ring false. Stay warm up there in the great white north, eh.

 

[traumateam1]

Thank-you. I really like that car accident vs. car fire situation, becuase it's so true. And people in the other thread, I think got a little confused just because (their argument) there was no neuro deficits present at the time. Anyways thank you guys for your participation and I'm trying to stay warm in this 30C weather

 

[Chiron]

Must be rough up there in British California. Take care. I'm out.