11/30/2015 KE 2. Penetrating Trauma. Overview. Physics of Penetrating Trauma

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1 Penetrating Trauma Spokane County EMS Overview Review of Kinematics Physics of Penetrating Trauma Pathophysiology of a gunshot wound What is cavitation Index of suspicion Wound Characteristics Treatment Working with law enforcement Physics of Penetrating Trauma Remember the Kinetic Energy Equation?? Mass( weight) Velocity( speed) KE 2 2 Greater the mass the greater the energy Double mass= Double KE Greater the speed the greater the engery Double speed = 4x increase in KE 1

2 Physics of Penetrating Trauma Small & Fast bullet can cause greater damage than large and slow. Different bullets of different weights traveling at different speeds cause Low Energy/Low Velocity Knives and arrows Medium Energy/Medium Velocity Weapons Handguns, shotguns, low-powered rifles mps High Energy/High Velocity Assault Rifles 600-1,000 mps Maybe they are not just shot.. What if it doesn t enter the body? Secondary Impacts Bullet striking other objects can cause yaw and tumble Body Armor (Kevlar) Transmits energy throughout entire vest resulting in blunt trauma Myocardial Contusion Pulmonary Contusion Rib Fractures 2

3 They are all different! Pathophysiology of a gunshot wound Projectile Injury Process Tip impacts tissue Tissue pushed forward and to the side Tissue collides with adjacent tissue Shock wave of pressure forward and lateral Moves perpendicular to bullet path Rapid compression, crushes and tears tissue Cavity forms behind bullet pulling in debris with suction. Visual Learning 3

4 The bullet does cause damage but is that it? Direct Injury Damage done as the projectile strikes tissue Pressure Shock Wave Human tissue is semi-fluid Solid and dense organs are damaged greatly Temporary Cavity Due to cavitation Permanent Cavity Due to seriously damaged tissue Zone of Injury Area that extends beyond the area of permanent injury Apply what you see here.. 4

5 Low Velocity Objects Knives, Ice-picks, Arrows Flying objects or debris Injury limited to tissue impacted Object pathway Object twisting or moved Oblique angle 2 Inches Index of Suspicion Density of tissue affects the efficiency of energy transmission Resiliency Strength and elasticity of an object Connective Tissue Absorbs energy and limits tissue damage Organs Solid Organs Dense and low resilience Hollow Organs Fluid filled: transmit energy = increased damage Air filled: absorbs energy = less damage 5

6 Lungs Air in lung absorbs energy Pneumothorax or hemothorax Bone Resists displacement until it shatters Alters projectile path Extremities Injury limited to resiliency of tissue 60-80% of injuries with <10% mortality Index of Suspicion Index of Suspicion Abdomen (Includes Pelvis) Highly susceptible to injury and hemorrhage Bowel perforation: hrs peritoneal irritation Thorax Rib impact results in explosive energy Heart & great vessels have extensive damage due to lack of fluid compression Any large chest wound compromises breathing Neck Damages Trachea and Blood Vessels Neurological problems Sucking neck wound Head Cavitational energy trapped inside skull Serious bleeding/death What are your concerns? What lethal injury can this person have? What would be your first priority? Does this injury require c-spine? 6

7 Entrance Wounds Size of bullet profile for non-deforming bullets Deforming projectiles may cause large wounds Close Range Powder Burns (Tattooing of powder) 1-2 mm circle of discoloration Localized subcutaneous emphysema Exit Wounds Appears to be Blown outward Pressure wave Wound Characteristics What good does a great head-to-toe assessment do? What type of injury does this look like? What could have caused this? Guess we should go look to find clues! When to use an occlusive dressing Open Chest Wound May or may not be a sucking sound Seal wound as soon as possible Gloved hand Occlusive dressing Think entrance and exit wounds High Flow O2 Treat for Shock Monitor patient for any complications or buildup of pressure. If S/S of tension pneumothorax appear you need to burp the dressing to relieve the pressure 7

8 Tension Pneumothorax Penetrating injuries and C-spine Would you need to c- spine this injury? How would you do it? What would you want to know if you were going to not c-spine? PHTLS 8 th edition guidelines PHTLS A little different than what we have done in the past! How many agencies out there are doing this? 8

9 Special Concerns with Penetrating Trauma Impaled Objects Low-energy Dangerous to remove DO NOT REMOVE UNLESS In Cheek/ Airway Obstruction Interferes with CPR: ASSESS!!! Treatment is pretty straight forward right? H-ABC Life threatening hemorrhage Airway Breathing Circulation They still take priority over minor bleeding or injuries Direct pressure Stop the bleeding! If pressure is not working tourniquet Consider occlusive dressing for chest and neck wounds With Penetrating Injuries Comes the Chance of Working with Police. Entering the Scene You must try to carry out your duties with minimal impact on potential evidence Entry or exit to the scene that was not used by a suspect 9

10 Care on the Scene of a Crime Be observant and look for hazards Touch only what is required for patient care Wear gloves Watch where you step Bring only necessary equipment and personnel only Document your observations Treatment and Assessment DO NOT Cut through bullet holes or stab wounds in clothing Shake or turn clothing inside out Leave medical packaging or gloves at the scene Rely on your memory Alter position of evidence unless absolutely necessary Step in blood stains or splattered blood Touch weapons or bullets Document, Document, and Document Note and document in writing the following: evidence of forced entry room layout location of patient location of weapons or potential weapons signs of struggle bullet casings or cartridges What other things do you think should be documented? 10

11 Your Patient: Assessment and Treatment Dangers? What areas are of concern? Treatment? Transport? Questions? POST-TEST 1. What type of weapon is a Medium Energy/Velocity weapon? A. Arrow B. Assault Rifle C. Knife D. Shotgun 2. Which of the following injuries can patients wearing body armor sustain? A. Myocardial Contusion B. Rib Fractures C. Pulmonary Contusions D. All of the above 3. Which of the following injuries would require an occlusive dressing? A. Entrance wound on the right thigh B. Impaled fork in the left cheek C. Stab wound to the right lateral chest wall D. GSW to the right index finger 11

12 4. When is it ok to remove an impaled object? A. When you need to fit them in the ambulance B. When it interferes with CPR C. When it is in the neck D. None of the above 5. What should you NOT do at a crime scene? A. Cut through bullet holes or stab wounds in clothing B. Play with the gun or knife C. Step in the blood stains or splatters D. All of the above SECRET QUESTION What is the Kinetic Energy Equation? Special thanks to Sheila Crow Stitchin Dreams Embroidery wcsocrow@yahoo.com For providing our Secret Question prize 12

13 Questions? Contact: Samantha Roberts Fax: Updates Please EMS presentation, all certificates will be printed by participants or their agency. The certificate template will be available through the health training website at the same location as all presentation downloads. It will be posted the day after each monthly presentation. 13

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