chbare Posted June 8, 2006 Share Posted June 8, 2006 You are called to the scene of a shooting. Dispatch informs you that there is a 43 year old male with a GSW to his chest. You arrive on scene and note that police have it secured. There is a BLS crew on scene rendering care to the patient. The patient has just been loaded in the back of their ambulance and it looks like they are bagging him. What else would you like to know? Take care, chbare. Link to comment Share on other sites More sharing options...
AZCEP Posted June 8, 2006 Share Posted June 8, 2006 Location/size of wound. BVM compliance/heart rate/GCS? Link to comment Share on other sites More sharing options...
chbare Posted June 8, 2006 Author Share Posted June 8, 2006 AZCEP, it is cold outside , so the patient is in heavy clothing, but the basic crew cut the patients coat and shirt off. You note a small round hole to the center of the sternum. (about 1.5 cm in diameter) There is a scant amount of bleeding oozing from the hole. You also note a small amount of blood just under the left axilla. GCS; E-1, V-1, M-1. You palpate a very weak radial pulse of 128. The EMT-B bagging reports that it is very easy to ventilate, another EMT-B is holding the mask and it looks like he is doing a good job of maintaining an adequate seal. Take care, chbare. Link to comment Share on other sites More sharing options...
AZCEP Posted June 8, 2006 Share Posted June 8, 2006 Any JVD? Breath sounds? Sounds like basic trauma care at this point. Continue with BVM, start two large IV's, seal the holes, intubate. Based on the information, this individual is in Class IV shock, so should probably get a bit of fluid and rapid transport. This is far too simple though, and I'm anxiously waiting for the other shoe to drop. Link to comment Share on other sites More sharing options...
chbare Posted June 8, 2006 Author Share Posted June 8, 2006 AZCEP, you do not note any JVD. There are clear lung sounds with equal and bilateral expansion noted with ventilations. A dressing is placed over the small wound to the sternum, you also note what looks to be a slightly larger wound under the left axilla where you saw the blood earlier. It is slightly larger than the wound to the sternum and you suspect this may be an exit wound. You place a dressing over this wound as well. The patient is intubated with an 8.0 ETT and placement is confirmed. You note very good compliance with ventilations. Two large bore peripheral IV life lines are placed and the patient receives a bolus of NS. After the fluid you do not note any change in his mental or hemodynamic status other than a very weak pulse of 130. Transport time is 30 minutes. Take care, chbare. Link to comment Share on other sites More sharing options...
Punisher Posted June 8, 2006 Share Posted June 8, 2006 Why the fluid bolus? What was his BP? If he had a radial pulse that implies probably at very least 70-80 mmHg for an SBP (granted MAP is better for assessing the management of hemorrhagic shock, but ok...). Are heart sounds muffled? Link to comment Share on other sites More sharing options...
vs-eh? Posted June 8, 2006 Share Posted June 8, 2006 Transport time is 30 minutes. Get your dialing finger ready for that pronouncement. Check his sugar. I bet he's hypoglycemic... Oh and a chest needle ready too... Link to comment Share on other sites More sharing options...
AZCEP Posted June 8, 2006 Share Posted June 8, 2006 Why the fluid bolus? What was his BP? If he had a radial pulse that implies probably at very least 70-80 mmHg for an SBP (granted MAP is better for assessing the management of hemorrhagic shock, but ok...). Are heart sounds muffled? Actually, MAP is better suited to obstruction related issues. We would really need to know the pulse pressure to guide treatment. Yes, I am aware that the MAP is related to pulse pressure, but the width of the pulse pressure would better guide us. The main issue is his lack of cerebral perfusion. Great he has a tachycardic, radial pulse, but not enough blood getting to the brain. We need to give enough fluid to maintain things where they are. Since we are already well behind the curve, we need to get some fluid into this patient. Figure he is lying supine, and still has inadequate cerebral perfusion = volume depletion. Heart sounds would be good to know, but I wouldn't rely on them much in the absence of JVD. Link to comment Share on other sites More sharing options...
Ace844 Posted June 8, 2006 Share Posted June 8, 2006 Actually, MAP is better suited to obstruction related issues. We would really need to know the pulse pressure to guide treatment. Yes, I am aware that the MAP is related to pulse pressure, but the width of the pulse pressure would better guide us. The main issue is his lack of cerebral perfusion. Great he has a tachycardic, radial pulse, but not enough blood getting to the brain. We need to give enough fluid to maintain things where they are. Since we are already well behind the curve, we need to get some fluid into this patient. Figure he is lying supine, and still has inadequate cerebral perfusion = volume depletion. Heart sounds would be good to know, but I wouldn't rely on them much in the absence of JVD. "Azcep," Correct me if I'm wrong, but don't you need to know the MAP to figure out CPP...and or ICP? ACE844 Link to comment Share on other sites More sharing options...
AZCEP Posted June 8, 2006 Share Posted June 8, 2006 I did not indicate we need the ICP or CPP only the pulse pressure to decide degree of shock Difference between systolic and diastolic = pulse pressure. When this narrows we can quickly determine that a patient is compensating for volume loss. Yes, the MAP would be nice to know, as would the pressures you describe, but for the quick and simple, just use the pulse pressure and use the fluid of choice (NS, LR, diesel) to maintain it. Link to comment Share on other sites More sharing options...
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