DesertEMT Posted February 28, 2012 Share Posted February 28, 2012 You and your partner are on your way to a residential neighborhood for a patient with multiple gunshot wounds, police are already on scene and have the suspected shooter in custody. As you arrive on scene you apply BSI and step out of your vehicle and are briefed by local police "the victim is a 17 year old high school senior who was attending a local house party when the gunmen approached the teen and fired 3 shots at a distance of 4ft." As you approach the patient you notice he is tracking you with his eyes but is keeping his head down, the patients is sitting slumped against a wall and is covered in blood. Go Link to comment Share on other sites More sharing options...
Vorenus Posted February 28, 2012 Share Posted February 28, 2012 Is ABC okay? Ausculatation - results? Undress patient - what do we say. Where are the GSW? Exit wounds? Vitals? GCS? Neurological examination - results? What weapon was used? What ammu? Link to comment Share on other sites More sharing options...
DesertEMT Posted February 28, 2012 Author Share Posted February 28, 2012 Is ABC okay? Ausculatation - results? Undress patient - what do we say. Where are the GSW? Exit wounds? Vitals? GCS? Neurological examination - results? What weapon was used? What ammu? Airway is open but their is blood in his mouth Breathing is rapid and shallow pulse is rapid and thready, skin is clammy and pale Upon auscultation you note absent lung sounds on left side Patient shot 3 times, you note one entry and exit wound on left pectoral just above the nipple, another e/e wound in the upper left abdominal quadrant, and a third wound entry only in the lower left quadrant Vitals are BP 110/65, R/R 28 rapid and shallow, HR 110bpm GCS 14 Weapon was a Glock 26 with 9x19mm rounds Link to comment Share on other sites More sharing options...
runswithneedles Posted February 29, 2012 Share Posted February 29, 2012 (edited) JVD trachea- is it mid line what does his abdominal region look like is it tender, rigid is there a sucking chest wound approx how much has he bled out onto the floor? Does he feel nauseous? Any unusual odors such as GI odors Go ahead and assist ventilations BVM hooked up to 02 trendleburg postion have 2 IVS ready to go once he begins entering decompensated shock manage any bleeding and cover any sucking chest wounds with a three sided occlusive dressing Prepare for a L sided needle decompression if indicated *EDIT:TKO....Until signs of decompensated shock are present and titrate to maintain a BP of 90 mmHg systolic Go ahead and place on cardiac monitor as well. Also clear airway with suction Edited February 29, 2012 by runswithneedles Link to comment Share on other sites More sharing options...
nypamedic43 Posted February 29, 2012 Share Posted February 29, 2012 (edited) You dont want to decompress in the side, thats where ED staff will put a chest tube. Decompress mid clavicular just over the 3rd rib. Repeat as necessary. Start 2 large bore IV's with ringers left at KVO rate. His pressure is good at 110. Cant be sure that there isnt a tamponade going on though and his breathing should inprove with the decompression. If it doesnt, there could be a tamponade. JVD and deviated trachea are late signs. Oxygen at 15 liters by NRM. Suction as needed Cardiac monitor and 12 lead 2 IV's of ringers at KVO rate to keep pressure where it is cover the entrance and exit wounds. How is his belly? rigid? distended? does he have rebound tenderness? The goal here is to load him and get moving and prevent decompensated shock from beginning. He doesnt need trendelenburg as he isnt hypotensive. Keeping him in a semi fowlers will help prevent blood from pooling in his airway but still suction as needed. Edited February 29, 2012 by nypamedic43 Link to comment Share on other sites More sharing options...
DesertEMT Posted February 29, 2012 Author Share Posted February 29, 2012 JVD trachea- is it mid line what does his abdominal region look like is it tender, rigid is there a sucking chest wound approx how much has he bled out onto the floor? Does he feel nauseous? Any unusual odors such as GI odors Go ahead and assist ventilations BVM hooked up to 02 trendleburg postion have 2 IVS ready to go once he begins entering decompensated shock manage any bleeding and cover any sucking chest wounds with a three sided occlusive dressing Prepare for a L sided needle decompression if indicated *EDIT:TKO....Until signs of decompensated shock are present and titrate to maintain a BP of 90 mmHg systolic Go ahead and place on cardiac monitor as well. Also clear airway with suction Trachea is beginning to show slight deviation to the right side Abdomen is rigid & distended with diffuse tenderness Chest wound is a sucking chest wound (sorry I forgot to mention that) patient admits to being nauseous and urinating himself, you note hematuria patient had lost almost 30% of his blood volume when you first arrived on scene and when you begin to load the patient onto the gurney his BP begins to drop, while his heart rate begins to increase, as does his respiration's. His mental status also begins to deteriorate, the patient shows a marked increase in anxiety and confusion Link to comment Share on other sites More sharing options...
DFIB Posted February 29, 2012 Share Posted February 29, 2012 Besides what has already been mentioned I would put the speed to this kid. The hematuria as he is going to get serious really fast. Also make sure he has a surgical team waiting at the hospital. Are the exit wounds bigger than the entry wounds? Would you consider sedating and entubating this patient? Link to comment Share on other sites More sharing options...
P_Instructor Posted February 29, 2012 Share Posted February 29, 2012 Initial question.....sucking chest wound on left and tracheal deviation to the right? What is the tension from? It's kind of cork the holes and diesel bolus the patient with the other interventions inbetween. Link to comment Share on other sites More sharing options...
chbare Posted February 29, 2012 Share Posted February 29, 2012 Also, is the patient spontaneously breathing? Spontaneously breathing with a sucking chest would would make it exceedingly difficult to tension. Link to comment Share on other sites More sharing options...
Chief1C Posted February 29, 2012 Share Posted February 29, 2012 Where's the nearest hospital? Looks like a tragic outcome in the making. Link to comment Share on other sites More sharing options...
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