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GSW vs Pentrating chest wound

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#1 jjd

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Posted 01 September 2010 - 09:09 AM

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, 01 September 2010 - 09:18 AM.

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Posted 01 September 2010 - 03:57 PM

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.
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#3 chbare

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Posted 01 September 2010 - 04:18 PM

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,
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#4 Kiwiology

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Posted 01 September 2010 - 06:46 PM

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.
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#5 FireMedic65

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Posted 01 September 2010 - 10:12 PM

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.
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