Introduction to the management of penetrating pre-hospital trauma.

1. ‘Gunshots & Stabbings’ An introduction to the management of pre-hospital trauma patients By Dr. Nic Sparrow MBBS, BSc, MRCGP Medical Director – Pre-Hospital Care World www.phcworld.org

2. Overview / Aims To discuss some of the general principles of managing penetrating trauma in the pre-hospital setting Look at some of the common injuries Review some essential interventions and skills needed to treat patients

3. The ‘CALL – OUT’ THINK SAFETY - SELF... Scene... and Survivors Plan your route, make a slow & safe approach / park defensively. Await the arrival of the police... Communicate arrival to control & other services Assess & Approach only if it is safe (remember it’s a crime scene – don`t become a casualty)

4. Management of Penetrating Trauma – ATLS Approach Pre-Hospital Care (PHC) Provider Airway Breathing Circulation Disability Exposure Assessment is often done simultaneously Always remember C-spine & Massive Haemorrhage Control Ask yourself 1) What is the diagnosis ? 2) How severe is it ? 3) Can it be reversed ? 4) Is reversal needed now ?

5. (A) Airway / C-Spine Protection PHC Provider Rapid Assessment of the Airway / C-spine is required Remember C-spine / Massive Haemorrhage Control may pose an immediate threat to life and may need to take priority before airway Bullet lodged close to the cervical spine

6. ‘Penetrating extremity trauma can quickly lead to Massive Haemorrhage and death’

8. Facial / Mandibular #’s

9. Tracheal / laryngeal #’s

10. Expanding haematomasAll can lead to airway obstruction and death Consider the risks of Air Embolus in vascular injuries to the neck

12. Airway interventions depend upon the patient`s injuries, the level of skill and equipment of the provider:- Oxygen 15L (Reservoir Bag) Oropharyngeal airway Nasopharyngeal airway Extraglottic Devices Endotracheal intubation Emergency Cricothyroidotomy

14. Surgical Cricothyroidotomy Indicated when:- Can’t ventilate / Can’t Intubate Sedate Patient Scalpel 1cm Stab incision into the cricothyroid membrane Insert Size 5-6 ET tube Secure the ET tube Definitive Tracheostomy will be required

16. Auscultation – Air entry, breath sounds, vocal fremitus

17. Percussion – Dull / hyperesonant

19. Airway obstruction

20. Tension pneumothorax

21. Open pneumothorax

22. Massive Haemothorax

23. Instability of chest wall (flail Chest & contusions)

24. Cardiac Tamponade

25. Tracheal or Bronchial Injury

27. Right Sided Pneumothorax

28. Consider other possible Structures Injured e.g. oesophagus

29. Large Right Haemothorax

31. ↓ GCS can be caused by ↓ cerebral perfusion secondary to haemorrhagic shock

33. Auscultation – heart sounds ? muffled

35. Do not place IV’s on the same side as the injury if possible

37. Never forget pelvic fractures as a cause for hypotension Beware the ‘thirsty’ patient Blood on the floor Look for 4 more (Chest / Abdomen / Pelvis / Femur)

39. Assess the GCS

40. Pupils