Treating GSWs

[Bladerunner13]

Anyone in this forum able to recommend a course on learning to treat Gunshot wounds?

Somewhere in the Memphis area would be nice, but I'm willing to travel.

Thanks

[gruntmedik]

This assumes you are a 1st responder or above. If you are not, an EMT class or American Red Cross would be my best guess.

As far as pre-hospital treatment goes, it is really no different from any other open wound. After the obvious stuff--scene safety, number of pt's, etc..., just follow the ABC's:

Airway-if they can't maintain one, maintain it for them
Breathing-if they aren't adequately, breathe for them
Circulation-If they have none, CPR or determination of death protocol; If they are bleeding, stop it. Cover the wound, 2 large bore IV's.

Unless it is an isolated extremity injury, all GSW's should have C-collar, and LSB.

Is there an exit? NEVER document entrance and exit wounds, you will be eaten alive if you go to court--just document penetrating wound and note location and description.

If the pt is able to talk, ask how many shots, handgun/long gun, distance from muzzle.

[jmshady]

PHTLS or BTLS are great classes and give you the CE you need.

[akulahawk]

Originally posted by jmshady
PHTLS or BTLS are great classes and give you the CE you need.

If you're already certified as an EMT or higher, these classes are really good at training you how to handle traumatic injuries.

For pure GSW (no other injuries), a C-Collar and LSB are generally not necessary unless there is an actual hit to the spinal column or there is some other structural problem present that needs to be stabilized (shattered pelvis for example). FWIW, I have never heard of a head GSW causing a spinal injury. The LSB and C-collar make prehospital handling easier though. IF the patient requires intubation, I WILL put them on a LSB with a collar because this helps prevent dislodgement of the tube.

For multi-system trauma or unknown trauma patients, this is a different story...

[akulahawk]

Originally posted by gruntmedik
This assumes you are a 1st responder or above. If you are not, an EMT class or American Red Cross would be my best guess.

As far as pre-hospital treatment goes, it is really no different from any other open wound. After the obvious stuff--scene safety, number of pt's, etc..., just follow the ABC's:

Airway-if they can't maintain one, maintain it for them
Breathing-if they aren't adequately, breathe for them
Circulation-If they have none, CPR or determination of death protocol; If they are bleeding, stop it. Cover the wound, 2 large bore IV's.

Unless it is an isolated extremity injury, all GSW's should have C-collar, and LSB.

Is there an exit? NEVER document entrance and exit wounds, you will be eaten alive if you go to court--just document penetrating wound and note location and description.

If the pt is able to talk, ask how many shots, handgun/long gun, distance from muzzle.

I will echo most of this... but rephrased.

Treat the ABC's first. Then treat bleeding wounds like any other bleeding wound - cover it then: direct pressure, elevation, pressure point, and tourniquet as necessary. Use IV fluids as necessary to maintain a systolic BP of 90. The idea is not to "pop the clot".

Head, Neck, Chest and Abd wounds: cover, begin transport, start IV's enroute to maintain SBP at 90.

Document the location of any penetration wounds do NOT call them "entrance" and "exit" wounds. If you do, you will be made a fool of in court unless you are a subject matter expert in that field.

IMHO- in the setting of trauma, if the patient is VSA when you find them, they're usually DRT.

[jmshady]

Originally posted by akulahawk
If you're already certified as an EMT or higher, these classes are really good at training you how to handle traumatic injuries.

For pure GSW (no other injuries), a C-Collar and LSB are generally not necessary unless there is an actual hit to the spinal column or there is some other structural problem present that needs to be stabilized (shattered pelvis for example). FWIW, I have never heard of a head GSW causing a spinal injury. The LSB and C-collar make prehospital handling easier though. IF the patient requires intubation, I WILL put them on a LSB with a collar because this helps prevent dislodgement of the tube.

For multi-system trauma or unknown trauma patients, this is a different story...

Personal experience from Iraq...

Pt had GSW upper Abdomen with no exit wound. Came from the field without c spine or backboard. The pt was crashing fast and no exit so the doc ordered a Chest and abdomen CT with contrast. On CT it revealed that C7 and T1 had stopped the bullet and the bleeding came from the spinal arteries. My lesson learned was Spinal precautions on all GSW's except isolated extremity wounds. GSW to the head and Spinal Precautions are the last thing I worry about.

[D25]

Originally posted by akulahawk

For pure GSW (no other injuries), a C-Collar and LSB are generally not necessary unless there is an actual hit to the spinal column

How are you going to know that pre-hospital?

PS Bladerunner, check out PHTLS.

[MDT]

A C-collar wouldn't have prevented neurologic injury if the bullet was stopped by C7-T1 though it may prevent further injury. Spinal artery bleeding won't be helped by LSB or C collar. LSB are torture devices. After my primary survey (ABCD) I remove the patient from the spine board and proceed to the rest of the exam. Scoops and patient sliding devices may be used instead. Plenty of studies to show the rapid onset of compression injury in a very short period of time.

The American College of Surgeons has established Advanced Trauma Life Support to assist in (fairly) consistant treatment of trauma patients. The American College of Emergency Physicians (my membership here)is more or less (often times less) in agreement with the some of the parameters, though they tend to be very dogmatic.

If you are a first responder as posted previously, ALS measures are adequate. If you are LE or military affiliated, you could look into the Heckler and Koch course Tactical Emergency Medicine. A very good course (and 21 hours of CE!!). One of the instructors has posted on GT before (Traumadoc).

MDT

[akulahawk]

Originally posted by D25
How are you going to know that pre-hospital?

PS Bladerunner, check out PHTLS. Originally posted by MDT
A C-collar wouldn't have prevented neurologic injury if the bullet was stopped by C7-T1 though it may prevent further injury. Spinal artery bleeding won't be helped by LSB or C collar.
-snip-
Plenty of studies to show the rapid onset of compression injury in a very short period of time.

Originally posted by D25
How are you going to know that pre-hospital?

PS Bladerunner, check out PHTLS.

For D25: This would be relatively easy to determine in the field... any neuro deficit? My primary focus is on ABC's initially anyway.

For MDT: I would suspect that a compression injury would occur fairly rapidly and would not be helped by LSB or any other immobilizaton means. For that I'd suspect the treatment would/could involve steroid / anti-inflammitory use and/or surgical decompression...

From my perspective, the result of the initial exam and conditions under which the exam was performed (battlefield?) would drive my initial treatment and packaging.

[akulahawk]

BTLS was also a good class...

I'd love to take a Tac-Med course. Not enough time and not enough $$$ to take it.:frown:

[jmshady]

Originally posted by MDT
A C-collar wouldn't have prevented neurologic injury if the bullet was stopped by C7-T1 though it may prevent further injury. Spinal artery bleeding won't be helped by LSB or C collar. LSB are torture devices. After my primary survey (ABCD) I remove the patient from the spine board and proceed to the rest of the exam. Scoops and patient sliding devices may be used instead. Plenty of studies to show the rapid onset of compression injury in a very short period of time.

The American College of Surgeons has established Advanced Trauma Life Support to assist in (fairly) consistant treatment of trauma patients. The American College of Emergency Physicians (my membership here)is more or less (often times less) in agreement with the some of the parameters, though they tend to be very dogmatic.

If you are a first responder as posted previously, ALS measures are adequate. If you are LE or military affiliated, you could look into the Heckler and Koch course Tactical Emergency Medicine. A very good course (and 21 hours of CE!!). One of the instructors has posted on GT before (Traumadoc).

MDT

No it would not have but the point was, no matter where you have an entrance wound in the chest/abdomen it is good practice to board and collar. Most services have a standing order to do so and erery ER Doc i have come in contact with would take a little bit of my butt off if I did not. If the round would have destroyed C2/C3 a collar would have helped but we do not have X-Ray in the back of a truck yet. Untill then I will play it safe. Hell a board would not have helped that pt, the damage had been done, but try to tell a lawyer that in court.

And yes I am a big fan of the scoops, It is a seldom used piece of equipment that can be very beneficial and even a back saver at times.

[MDT]

akulahawk..I should have been more specific. By compression injury I am referring to tissue damage leading to decubitus ulcers from laying on that hard damned board. There have been studies done (the more comical ones using ER residents) demonstrate that it takes only a very short period if time before stage I damage can begin. I have seen trauma patients transferred to my facility from rural EDs who have been on LSB for hours. This is ridiculous and harmful to the patient as there is very little actual spinal immobilization that occurs.

jmshady, yes it is a good idea to collar however by using the Nexus criteria in the field may be the way to go (more studies in pre-hospital setting). If you can clinically clear the c spine (again, the criteria MUST be adhered to strictly), the patient would be more comfortable.

I will say that there are very few times that the LSB has changed my treatment. The EMS service that runs for us has orders to board and collar anyone who sneezes or doesn't run fast enough to get away from them. A barbaric practice that frankly has very little clinical significance, and thankfully the research is bearing this out.

[akulahawk]

Originally posted by MDT
akulahawk..I should have been more specific. By compression injury I am referring to tissue damage leading to decubitus ulcers from laying on that hard damned board. There have been studies done (the more comical ones using ER residents) demonstrate that it takes only a very short period if time before stage I damage can begin. I have seen trauma patients transferred to my facility from rural EDs who have been on LSB for hours. This is ridiculous and harmful to the patient as there is very little actual spinal immobilization that occurs.

jmshady, yes it is a good idea to collar however by using the Nexus criteria in the field may be the way to go (more studies in pre-hospital setting). If you can clinically clear the c spine (again, the criteria MUST be adhered to strictly), the patient would be more comfortable.

I will say that there are very few times that the LSB has changed my treatment. The EMS service that runs for us has orders to board and collar anyone who sneezes or doesn't run fast enough to get away from them. A barbaric practice that frankly has very little clinical significance, and thankfully the research is bearing this out.

IIRC Stage I decub damage when on a LSB starts within about 45 minutes... I'd prefer to use a Vac-Mat type of immobilization device as they're better with lateral and vertical support (less movement) however they don't do as well with head immobilization than what you'd get with a traditional LSB with a head immobilizer device. The mats are supposed to be much more comfortable than the LSB and delay the onset of stage I decub. injury. The upshot is that Vac-Mat type devices are generally radiotranslucent and you can get a good CT image through them. Unfortunately, most medical personnel here in the US don't know much about them and frequently just cut them off.

They're just as easy as an airsplint to put on, are just as supportive as airsplints and far less painful to remove.

[jmshady]

Originally posted by MDT


jmshady, yes it is a good idea to collar however by using the Nexus criteria in the field may be the way to go (more studies in pre-hospital setting). If you can clinically clear the c spine (again, the criteria MUST be adhered to strictly), the patient would be more comfortable.

I will say that there are very few times that the LSB has changed my treatment. The EMS service that runs for us has orders to board and collar anyone who sneezes or doesn't run fast enough to get away from them. A barbaric practice that frankly has very little clinical significance, and thankfully the research is bearing this out.

But until the "Standards of Care" that have been around since Jonny and Roy change to allow us to make that kind of call, without a lawsuit, in the field. There are not many medical directors that will change the standing orders. I have cringed at times when putting a pt on a LSB. Knowing full well it will be off the Pt before report can be finished. You can make the call right and the pt can survive but a lawyer who knows what we should have done can get a settelment out of it. That is where the problem with Medics clearing C-spine in the field lays. It is too easy to find a Medic that will say "I would have done that" or "that is how we are trained" in court and there goes your cert. or at least job.

Since PHTLS kinda started it look at that course. I specifically rember a question on the test about a fall by a Skateboarder and the wrong answer involved a Collar and LSB. However the course said any fall from any height bought spinal precautions.

MDT what are your feelings on the use of the KED at MVAs. Alot of medics just do a Rapid Extrication on stable Pts. Is it worth it to use the KED?

[Glkster19]

Originally posted by MDT
I will say that there are very few times that the LSB has changed my treatment. The EMS service that runs for us has orders to board and collar anyone who sneezes or doesn't run fast enough to get away from them. A barbaric practice that frankly has very little clinical significance, and thankfully the research is bearing this out.


We have gotten away from boarding pts all the time. As long as the mechanism doesn't dictate, they're assessed for nk/bk pain. If thats negative you have them turn their head from side to side while holding c-spine yet. If all the above is negative and there is no numbness/tingling to extrmities we may disregard the LBB. If all the above is negative but a car is demolished or there was any significant MOI, they state we will collar/board.

[MDT]

My apologies to Bladerunner....we have deviated from the GSW aspect (I still say H&K Tac-Med course!!!).

jmshady...KEDs probably have their place. I would say that 99% of my patients I receive boarded and collared are without injury. It is the 1 patient that may have a c spine injury that the pre-hospital guys have to worry about. I will rail and moan about the overuse of immobilization, but I am not there when the medics arrive on scene. I can't fault anyone for performing their job and doing their best in the interest of the patient. So, whether KED, Philly collar, LSB, or whatever, if the medics thought they may need it, that's their clinical judgement. Better to over do than under do.

Having said that...don't get me started on our EMS giving charcoal to all of the suspected overdoes...a whole other soapbox!!


MDT

[akulahawk]

Originally posted by Glkster19
We have gotten away from boarding pts all the time. As long as the mechanism doesn't dictate, they're assessed for nk/bk pain. If thats negative you have them turn their head from side to side while holding c-spine yet. If all the above is negative and there is no numbness/tingling to extrmities we may disregard the LBB. If all the above is negative but a car is demolished or there was any significant MOI, they state we will collar/board.

Probably the biggest thing I learned in the years before becoming an EMT and Paramedic: MOI only points to the possibility of an injury and where such an injury may be located. No MOI = No injury.

It is the actual exam that will tell you whether or not an injury has occurred. EMS tends to overtreat and overtriage.

[Glkster19]

Originally posted by akulahawk
EMS tends to overtreat and overtriage.


Makes it hard to get sued that way, doesn't it. :clown:

[jmshady]

Originally posted by Glkster19
Makes it hard to get sued that way, doesn't it. :clown:

Excatly my thoughts. I would hate to not do something that takes five mins on scene to do and spend a total of 15-20 mins with the reason I am unempolyed.

[Glkster19]

Truthfully, EMS is 1 of the hardest professions to get sued in, at least sucessfully sued anyways. You generally have to be fairly negligent to get found to be improper. A lot of times we have SHTF with seconds to make a reasonable decision as far as someone's care provided to them. I'm not saying you can't be so don't take it the wrong way. At least in MI (don't know about the rest of the states), the gov't provides provisions that make it tougher to go after EMS.

[akulahawk]

Originally posted by Glkster19
Makes it hard to get sued that way, doesn't it. :clown:

Actually, your best chance of not being sued is to have not been born...

The key to not being successfully sued is to be able to articulate the reason for the care you gave - and a really good way to do this years down the road is to make sure you document your findings well. In any event, if you break any one of the 4 things necessary in finding you negligent, you have broken the case for negligence.

[Glkster19]

Originally posted by akulahawk
Actually, your best chance of not being sued is to have not been born...

The key to not being successfully sued is to be able to articulate the reason for the care you gave - and a really good way to do this years down the road is to make sure you document your findings well. In any event, if you break any one of the 4 things necessary in finding you negligent, you have broken the case for negligence.



Agreed on all comments, especially the 1st.

[akulahawk]

Originally posted by Glkster19
Truthfully, EMS is 1 of the hardest professions to get sued in, at least sucessfully sued anyways. You generally have to be fairly negligent to get found to be improper. A lot of times we have SHTF with seconds to make a reasonable decision as far as someone's care provided to them. I'm not saying you can't be so don't take it the wrong way. At least in MI (don't know about the rest of the states), the gov't provides provisions that make it tougher to go after EMS.

The land of Fruits and Nuts (California) also has legislation and regulations to this effect as well. I generally have to be found to be grossly negligent to have any adverse action taken against my license. Actually, in the county I live in, I can actually do more OFF duty than ON duty simply because of the documentable training I've had and the local EMS protocols allowing full ALS if the equipment is available.

[10 Ring Tao]

I didn't see an occlusive dressing mentioned for sucking chest wounds/lung shots.

[akulahawk]

Originally posted by 10 Ring Tao
I didn't see an occlusive dressing mentioned for sucking chest wounds/lung shots.

Ya know, it hasn't come up yet. In this thread, the OP asked about where to get training to treat GSW's.

Honestly, for those kinds of wounds, I'm probably going to ultimately place a butterfly valve dressing and assess for tension pneumothorax. If that occurs, then I'll burp the dressing and/or do a needle thoracostomy, and make a flutter valve or put an Asherman Chest Seal on it...

A lot of what I will do depends on the patient and how well I assess the injury. I also know that if I'm wrong about the TPX, then I've just bought the patient a chest tube that wasn't necessary.

[jmshady]

Originally posted by akulahawk
Ya know, it hasn't come up yet. In this thread, the OP asked about where to get training to treat GSW's.

Honestly, for those kinds of wounds, I'm probably going to ultimately place a butterfly valve dressing and assess for tension pneumothorax. If that occurs, then I'll burp the dressing and/or do a needle thoracostomy, and make a flutter valve or put an Asherman Chest Seal on it...

A lot of what I will do depends on the patient and how well I assess the injury. I also know that if I'm wrong about the TPX, then I've just bought the patient a chest tube that wasn't necessary.

I just recerted on PHTLS I found it very interesting that they taught no flutter valve on ND. Very interesting.

[Solo1st]

we stopped flutter valving a few years ago, according to the trauma surgeons the chest wall defect had to exceed 1/3 the diameter of the trachea before air would preferentialy enter the defect/needle/etc.




another sacred cow gets slain, anyone bring the bar-b-que sauce? i'll bring the beer :beer:

[akulahawk]

Originally posted by Solo1st
we stopped flutter valving a few years ago, according to the trauma surgeons the chest wall defect had to exceed 1/3 the diameter of the trachea before air would preferentialy enter the defect/needle/etc.




another sacred cow gets slain, anyone bring the bar-b-que sauce? i'll bring the beer :beer:

Anytime you poke a hole the chest, you are going to have SOME air entrained into that cavity via that hole. The question then posed is: does this make any significant difference? The answer seems to be "probably not".

That being said, I'd still want to hedge my bets and place a one-way valve over that hole. Then again, I'd rather want to have a chest tube placed w/ suction if things were that bad...

[Parmaboy]

I have only had two GSW's, one was to the leg and had no airway problems. The second was to the chest though. I think it hit his trach just barely. I was amazed to see our chest decompresssions work. The reason I saw amazed is because yeah it sounds good in theory, but I didnt know if it actually worked(Now I know :-) ) The guy had no breath sounds on the left side. Stuck a 14ga in, put a 3-way stopcock on the end. And viola we heard breath sounds on that side.

[akulahawk]

Originally posted by Parmaboy
I have only had two GSW's, one was to the leg and had no airway problems. The second was to the chest though. I think it hit his trach just barely. I was amazed to see our chest decompresssions work. The reason I saw amazed is because yeah it sounds good in theory, but I didnt know if it actually worked(Now I know :-) ) The guy had no breath sounds on the left side. Stuck a 14ga in, put a 3-way stopcock on the end. And viola we heard breath sounds on that side.

Personally, I prefer using the 3 1/2" 12ga angiocaths for chest decompression. If available, I'd use a commercial flutter valve kit or an Asherman Chest Seal. The flutter valve kit allows you to hook the darned thing up to suction. :supergrin: That negative pressure works better... I most definitely believe that if you're going to dart the chest, you should be allowed to apply suction to eliminate air in the pleural cavity, whether you caused the leak or not.

In any event, needle decompression is at best a temporary solution. Definitive care requires placing a chest tube.