Welcome to EMT City
Register now to gain access to all of our features. Once registered and logged in, you will be able to create topics, post replies to existing topics, give reputation to other members, get your own private messenger, post status updates, manage your profile and so much more. This message will be removed once you have signed in.

GSW vs Pentrating chest wound

Posted (edited) · Report post

Hi all,

I have a scenario i would like to run past you.

You arrive on scene to find 2 patients.

1 x GSW abdo, no exit wound. Patient is approx 35 years old, weighs roughly 79KG's (sorry not sure how many pounds that is) BP 126/75, RR 25, GCS 12, HGT 4.2 (glucose) , Pulse 78. Slightly diaphoretic.

1 x Penetrating chest wound, stabbed with a 5 inch serrated blade at the second IC space, Mid clavicular line on the left side of his chest. Patient approx 35 years old, weight 79kg's, BP 115/72, RR 32, GCS 12, HGT 4.2, Pulse 89, you notice slight diaphoresis and what could possibly be jugular venous distension. Air entry seems = on both sides as does chest expansion.

Edit: Your ECG and pulse ox are not operational.

Your in an ALS response car and are met at the scene by 2 x BLS in an ambulance. You can only take one patient. Which one would get higher priority and get attention first and what would your treatment be? Your in South Africa where you are registered and considered an indepedant practitioner (in other words there is no such thing as calling medical control and it's your decision in the end) Edited by jjd
0

Share this post


Link to post
Share on other sites

Posted · Report post

Unfamiliar with local protocols, but-

I would give the GSW to the BLS guys, Start a couple large bore IV's(omit this if the BLS guys cannot transport with the IV's) 100% O2, high flow, treat for shock, bleeding control. MAST pants if applicable, treat for shock, and tell them to run like hell..

Why? Because other than large bore IV's, there is nothing more an ALS provider can do prehospitally for a GSW to the abdomen- at least until they arrest. Unclear where that bullet went, or where the damage is.

I would do the same treatment for the SW, but would take this patient because if they do develop a pneumo or tension pneumo, we can decompress that, whereas a BLS guy cannot.
In a triage situation, both patients would be considered reds or critical, so in your scenario, you need to dig deeper and consider the details and make a judgment call.
1

Share this post


Link to post
Share on other sites

Posted · Report post

I assume we are in the role of a B-tech paramedic?

I'd take them both in the ambulance but assume this scenario is so linear that we must choose one or the other? Clearly, the second patient, based solely on the information available, requires immediate intervention. Rapid transport, fluid challenge if needed as a temporary measure and take him to an appropriate medical centre.

Take care,
chbare.
0

Share this post


Link to post
Share on other sites

Posted · Report post

Take patient to hospital; decompress the pneumo and give a small fluid challenge to the GSW should they become indicated, little oxygen if they are hypoxaemic but that's about it.
0

Share this post


Link to post
Share on other sites

Posted · Report post

In the location of the stabbing, it is the same location where you would do a chest decompression. I would put on an occlusive dressing (BLS can treat a sucking chest wound and "burp" the dressing)

The GSW can present with little to no symptoms, aside from a hole in the belly, and the patient may look fine. As we know, the abdominal cavity will fill up and pool A LOT of blood. The patient will be going into shock and we will hardly notice it because there is little blood loss.

As for the stabbing, the location isn't quite as bad, but still pretty serious. There are lots of vessels on the inferior/posterior of those ribs. Having them hit with the knife can lead to serious problems. This patient will need a chest tube most likely, which can't be done in the field.

Like Herbie mentioned, these situations are just that... situational. Keeping calm and looking at the big picture is what is important here (if we are talking BLS or single crew). Using your best judgement and following triage protocols will most likely help you. It is hard to say which patient is more critical without more information.

If it were me, a single crew. I would do the rapid trauma assessment, stabilize best I can, and transport both at the same time and request another unit to rendezvous en route if possible.
0

Share this post


Link to post
Share on other sites

Posted · Report post

If the stabbing is really developing JVD, then we have to assume tamponade. Especially when we consider the location of the injury. This patient may quickly transition to a moribund state.

Take care,
chbare.
0

Share this post


Link to post
Share on other sites

Posted · Report post

Pretty tough one.

Im sending the SW first with the notification of going right behind them with the GSW.

#2 is already showing signs of a pnumo and A comes before C.

Wow I think that is the simpilest answer I have ever given here ;)
0

Share this post


Link to post
Share on other sites

Posted · Report post

It's not a pneumothorax that concerns me. In fact, that would be much preferred over what we must suspect.

Take care,
chbare.
0

Share this post


Link to post
Share on other sites

Posted · Report post

So the general consensus at the moment is that the SW be transported first based on.... raised JVD, pneumo and the possibility of a tamponade based on the wounds location? Firemedic made a good point that the wound is directly in the same location that a needle decompressionn would be done at. What alternatives do we have to relieve the tension? Would an occlusive dressing make the slightest difference to someone who is already presenting with raised JVD, which as we know present in the late stages of a tension pnuemo.

Sorry if this is a mundane scenario, i'm relatively new to ems and believe participating in a few scenarios would benefit me. The reason i posted this particular scenario is that i have a friend who is a new intern at a provincial hospital. She had a similiar situation although the decision she had to make was more along the lines of who would be admitted to surgery first (only one functioning operating room). In the end she decided to go with the GSW. Her decision was based solely on the fact that it was a gunshot vs stabbing and a GSW is generally considered higher priority then a stabbing. (she is not entirely sure her decision was the correct one)

I understand her line of thinking but i can't help but think that a penetrating chest wound may pose more of a risk then a low calibre bullet into the abdo. Yes there is the possibility of substantial blood loss and the fact that there is no exit wound makes me wonder what the bullet ricochet off and what else may potentially be damaged.
0

Share this post


Link to post
Share on other sites

Posted (edited) · Report post

[quote name='jjd' timestamp='1283415645' post='247134']
I understand her line of thinking but i can't help but think that a penetrating chest wound may pose more of a risk then a low calibre bullet into the abdo. Yes there is the possibility of substantial blood loss and the fact that there is no exit wound makes me wonder what the bullet ricochet off and what else may potentially be damaged.
[/quote]
First off, welcome to our world, where craziness is the norm.
In addition to internal bleeding from the GSW, there is the issue of dynamics from the bullet impact. With that in mind, the policies of NY State DoH, and the FDNY EMS Command, have the patient being long back board immobilized, in addition to trying to stop the bleeding. That may have been one of the concerns addressed by your intern friend, in making the decision to do the surgery on the GSW prior to the stab wound injury.
As to which patient should be transported first, local protocols, personnel training, and experience, will be involved in the decision.
Just as a mention: due to the dynamics of receiving a GSW, the body part will be kicked kind of hard. Soft Body Armor, the so-called "Bullet-Proof" vest (I say so called, because with the right ammunition, it [i]will[/i] be penetrated, like a 22 caliber through my EMS design T-Shirts) spreads the impact area to absorb the shock, hence the lack of body penetration. LEOs (Law Enforcement Officers) who have been shot in the armor have described it as like being hit with a 20 pound sledgehammer. Edited by Richard B the EMT
0

Share this post


Link to post
Share on other sites

Posted (edited) · Report post

Hi All,

There seems to be a focus on a tension pneumothorax in the case of the stabbing victim. If I am reading the scenario right, there is equal air entry and chest movement bilaterally. If the JVD was a result of a tension, there would be minimal if any chest movement or breath sounds on the left side, as JVD is a late indicator of this condition. I agree with CHBare that one would have to assume Tamponade is the cause of the JVD, which would lead me to make that patient the priority. This is not to say the GSW is not serious and would also require rapid intervention and transport, but being that I could only take one patient, the SW would be my first choice.

Thanks for reading,

Foz Edited by FozMedic
0

Share this post


Link to post
Share on other sites

Posted · Report post

From what I read, it's not a matter of 'who gets transported first', but a matter of 'who gets ALS treatment, and who gets BLS treatment.

Since pulse ox and cardiac monitors are not working (shouldn't that have been corrected at the begining of the shift, BEFORE you put 'in service'?), I would treat the stabbing victim as a potential hemothorax and cover the stab site with an occlusive dressing (if the weapon has already been removed) and tape it down on 3 sides. IV (NS/KVO)and pass him off to BLS. If the weapon is still in place, secure it with a 'donut dressing' and transport it as is.

The GSW is concerning me more. Low calibre (I'm presuming .22, .25, .32) with no exit wound. Since I'm not formally in a medic class, my treatment options are still in that 'grey area' due to I haven't learned them yet. The bullet could have gone anywhere in the body after the initial penetration, so even in the best case scenario, we're talking about multiple system involvement.

I would also be trying to figure out which pain med I could administer so that the patients are as comfortable as possible, without compromising respiratory function.



[quote name='HERBIE1' timestamp='1283356629' post='247095']
Unfamiliar with local protocols, but-

I would give the GSW to the BLS guys, Start a couple large bore IV's(omit this if the BLS guys cannot transport with the IV's) 100% O2, high flow, treat for shock, bleeding control. MAST pants if applicable, treat for shock, and tell them to run like hell.[/quote]

Herbie, if you remember, a penetrating abdominal injury is an automatic contraindication for MAST. Isn't a GSW to the abdo considered a 'penetrating abdominal injury'?
1

Share this post


Link to post
Share on other sites

Posted · Report post

[quote]

Herbie, if you remember, a penetrating abdominal injury is an automatic contraindication for MAST. Isn't a GSW to the abdo considered a 'penetrating abdominal injury'?
[/quote]

I admit it has probably been at least 15 years since I have used the MAST suit on a patient- we no longer even carry them. I do recall that in our system, penetrating abdominal injury was a RELATIVE contrainidication for MAST, meaning we could apply them, inflate all but the abdominal compartment (needed a DR's orders), but impaled objects and eviscerations were absolute contraindications. Pregnancy meant that with an MD's orders, you could also apply the suit and only inflate the legs.

Below is the part of the scenario that I was initially stuck on, and made a couple assumptions based on my interpretation of the situation. This simple phrase to me meant that there were 2 BLS rigs, and I would be able to jump on board with only one of the 2 patients to provide ALS care, so this was essentially about triaging. I may have misinterpreted these parameters, and if so, mea culpa.

[color="#000080"][u]Your in an ALS response car and are met at the scene by [/u][u]2 x BLS in an ambulance. You can only take one patient.[/u]
[color="#000000"]
I assumed that this meant there were 2 BLS rigs, and you- as the ALS provider- would be only able to provide ALS care to one of the patients, while the other would be transported BLS. I was trying to come up with BLS interventions and prioritizing the patients based on what I could do for them. As I mentioned, as an ALS provider, there would be little prehospitally I could do for the GSW to the abdomen. If the patient with the potential for a tamponade or pneumo crashed, I could provide help for that person beyond the scope of an EMTB . I was thinking in desperation mode- try everything you can based on a difficult situation- which is really what much of our jobs often entails. Obviously, transport times also play a key role in the decision making process for triaging, treatment, and transport.

[/color][/color]Brings back memories- some horrible, like power washing the remnants of a GI bleed or bloody trauma from the suit. When I first started in EMS, MAST pants were part of the protocol on nearly every cardiac arrest- traumatic or medical. We became quite proficient at quickly applying them- and even learned that by putting your arms through the suit's legs(which were already closed by the velcro) and grabbing the patients legs, we could simply slip them on the patient and all that was left was to apply the abdominal portion and inflate. The hardest part of the process became getting the suit out of the case- and keeping the ER staff from cutting them when they arrived at the ED, of course. LOL

Like the studies now indicate, their value for autotransfusion may have been neglible, but I found they were quite effective for splinting things like pelvic fractures. The patient was more comfortable, it made patient movement easier, and the often bumpy transport was much more comfortable for them.
Who knows-maybe MAST will someday make a come back since things in EMS old is sometimes new again: Think sodium bicarb.
I sincerely hope that rotating tourniquets have gone the way of the dinosaur, however.

Thanks for keeping an old fart like me on my toes, Lone Star.
1

Share this post


Link to post
Share on other sites

Posted · Report post

[quote name='Richard B the EMT' timestamp='1283438863' post='247137']
With that in mind, the policies of NY State DoH, and the FDNY EMS Command, have the patient being long back board immobilized, in addition to trying to stop the bleeding. [/quote]

Oye. They really need to read the Maryland study.

[quote]Herbie, if you remember, a penetrating abdominal injury is an automatic contraindication for MAST. Isn't a GSW to the abdo considered a 'penetrating abdominal injury'?[/quote]

Here penetrating abdominal trauma is considered one of the primary reasons FOR considering MAST. In fact its the most common scenario used at final practical testing. Penetrating chest trauma is an automatic no-go, however.
0

Share this post


Link to post
Share on other sites

Create an account or sign in to comment

You need to be a member in order to leave a comment

Create an account

Sign up for a new account in our community. It's easy!


Register a new account

Sign in

Already have an account? Sign in here.


Sign In Now