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Smokin Joe
09-30-2004, 20:41
Okay I don't post in this AO b/c I only know enough to be a first responder (cert expired like 3 years ago). So here is the deal, the FEDS booked some guys into my jail this afternoon. 1 individual had multiple stab wounds. He had been treated at the hospital and released. No big deal right? Well he starts knocking on his door for help. I look in and he is bleeding profusely out of his chest (the area in which 3 wounds were). What I and our nurse did worked to stop the bleeding but what should be done from start to finish? Here are pics of the wounds after the bleeding had stopped and he had been cleaned up.

ccrn
10-01-2004, 00:47
From the pictures the wounds look to be superficial although its difficult to tell.

Tx for you guys would depend on what you want to achieve.

If bleeding lay him flat with feet slightly elevated, pack the wounds with gauze, apply a pressure dressing and call EMS. Internal bleeding with tamponade or pneumo among other things would be of concern. Your facility must have protocols for situations like this?

If the wounds are just superficial and arent to be sutured they need to be irrigated, covered for a period of time, and tx with a course of abx. I would guess the lump is a hematoma or localized inflammation?

Wound care could be an irrigation with dressing change one to three times daily.

Your RN should know all of this.

I suggest an EMT-B course. Your emplyoyer might even pay for it-

Smokin Joe
10-01-2004, 01:34
ccrn,

Here is what we did.

1. My first question when I saw all the blood (about a half a pint) was should we call EMS? Our nurse said not yet.
2. I applied direct pressure for about 10 minutes
3. Nurse continued to monitor and clean patient
4. Bleeding dropped off substainally onces I applied direct pressure.
5. After about 20 mins the pictures were taken.

Here are my observations of the left wound:

The left wound (our left as you look at the patient) was the real bleeder in which I applied the direct pressure to. I could not tell how deep it was but when I initially assessed his wound the blood was coming from deep with in the cut it was not coming from the dermis or epidermis layer of tissue. The blood was also flowing out of the wound not a trickle.

We do have protocols when dealing with this but I asked you guys just to make sure we are good to go.

24601
10-01-2004, 01:42
I'm kinda suprised they didn't suture that one. For now, you guys seem GTG. If it starts bleeding again, I'd call EMS. He might need more fluids, it further treatment. I had many calls to the jail for pts. that were worst off than they looked. You have good judgment, so trust it. You've done good, don't doubt yourself.

Keep an eye on color, breathing, alertness, etc. I take it there weren't any bubbles coming from it? A little off from the lung, I know, but it's hard to tell how deep it is.

ccrn
10-01-2004, 09:29
We do have protocols when dealing with this but I asked you guys just to make sure we are good to go.


I hope I didnt give you the impression I didnt think you were aware of these. I was more curious what they were p/t this situation. Also I am wondering if you guys have an MD on staff that writes these for you regarding medical issues and emergencies.

From your description it seems like you guys did ok. My fear would be internal bleeding that might not manifest itself until later. Liability also comes to mind especialy in todays litigious climate.

Do you guys have a form of liability insurance that you carry aside from employer protection? Quite a few nurses carry private malpractice now. Sometimes the employer will defend RN's in a lawsuite only to turn around and sue them as individuals-

Smokin Joe
10-01-2004, 19:37
I hope I didnt give you the impression I didnt think you were aware of these. I was more curious what they were p/t this situation. Also I am wondering if you guys have an MD on staff that writes these for you regarding medical issues and emergencies.

From your description it seems like you guys did ok. My fear would be internal bleeding that might not manifest itself until later. Liability also comes to mind especialy in todays litigious climate.

Do you guys have a form of liability insurance that you carry aside from employer protection? Quite a few nurses carry private malpractice now. Sometimes the employer will defend RN's in a lawsuite only to turn around and sue them as individuals-

Yes I'm in a Cop Club that protects us from civil litigation.

Our Protocol's were written by a PA. Because my cheap ass county can't afford an MD on staff.

Normally I would have applied direct pressure and called medics but our nurse (who is almost a PA) said not yet so I waited.

ccrn
10-01-2004, 22:14
Normally I would have applied direct pressure and called medics but our nurse (who is almost a PA) said not yet so I waited.

Like I said it seems like you guys did ok. Saved you the risk and hassle of transport back to ER in anycase.

How did your guy do anyway?

BTW, BP q hour x 4 might be appropriate in your situation given the circumstances. A lowering systolic pressure, narrowing pulse gap, and tachcardia would be symptoms of concern among others (ie pallor, decreaseed mentation, decreased heart tones, tachnypea etc etc).

Of course nothing is a replacement for higher care (qualifyer)-

Smokin Joe
10-01-2004, 22:38
Like I said it seems like you guys did ok. Saved you the risk and hassle of transport back to ER in anycase.

How did your guy do anyway?

BTW, BP q hour x 4 might be appropriate in your situation given the circumstances. A lowering systolic pressure, narrowing pulse gap, and tachcardia would be symptoms of concern among others (ie pallor, decreaseed mentation, decreased heart tones, tachnypea etc etc).

Of course nothing is a replacement for higher care (qualifyer)-

Systolic is the second or lower number correct? I can take a bp but I forgot which is which.

The bleeder wound (come to find out) did puncture a lung however he had good respatory. A mild cough but no blood in his cough.

The entire thing was kinda wierd I have never seen a wound just start bleeding again once a person was cleared by the ER. But oh well...the guy is doing good now, well expect for the attempted muder charges he faces.

ccrn
10-02-2004, 09:51
Systolic (systole) is the higher value which is the part of the cardiac cycle that ejects blood volume from the heart, diastolic (diastole) is the lower value and is relaxation of the ventricles. Filling of the ventricles occurs during this phase.

So 120/80 is a "normal" BP for a man. The higher value could be referred to as 120 systolic (charted SPB 120). 140/80 is more typical of males older than 30. If you cant hear the pulse d/t too much background noise or hypotension you can often palpate (feel) it in the wrist as you let the cuff down. Practice on your friends (?) to become proficient with this technique.

A narrowing pulse gap would be the two values getting closer together ie 100/90.

Stroke volume is about 60-120mL per beat or cardiac output of 4-8L per minute-

swatsurgeon
10-03-2004, 15:48
this is either luck or survival of the most fit. Stab wounds "in the box" to the area of the chest where the heart and great vessels live is the reason to be evaluated in the trauma center. As you watched the 1/2 pint of blood escape, what would be the next move? Holding pressure works if his pectoral muscle is the offending bleeder, if it's an intercostal vessel, he'll bleed until he's hypotensive and short of breath...he would be bleeding into his chest, or he hit the heart or a MAJOR blood vessel and you would watch him turn a nice shade of purple as he dies infront of your eyes.
The moral is if someone is stabbed in the chest, they need a trauma center evaluation by a trauma surgeon who could fix the bleeding.
All of that said, he could live through all of his incarceration a develop a late complication like rupturing the injured vessel once it began to heal/remodel the vessel.
Word to the wise, all stabs are eval'ed in the trauma center and then releasaed to be incarcerated.
I bet this guy did fine...but will the next one with the same problem do as well?
T-2

Smokin Joe
10-03-2004, 19:19
this is either luck or survival of the most fit. Stab wounds "in the box" to the area of the chest where the heart and great vessels live is the reason to be evaluated in the trauma center. As you watched the 1/2 pint of blood escape, what would be the next move? Holding pressure works if his pectoral muscle is the offending bleeder, if it's an intercostal vessel, he'll bleed until he's hypotensive and short of breath...he would be bleeding into his chest, or he hit the heart or a MAJOR blood vessel and you would watch him turn a nice shade of purple as he dies infront of your eyes.
The moral is if someone is stabbed in the chest, they need a trauma center evaluation by a trauma surgeon who could fix the bleeding.
All of that said, he could live through all of his incarceration a develop a late complication like rupturing the injured vessel once it began to heal/remodel the vessel.
Word to the wise, all stabs are eval'ed in the trauma center and then releasaed to be incarcerated.
I bet this guy did fine...but will the next one with the same problem do as well?
T-2

I was thinking along the same lines as you swatsurgeon. "Screw this direct pressure stuff call the medics....get this dude to a hospital" But he had already been evaluated by a trauma center and they said he was cleared to go to jail. So I believe that is why our nurse decided not to call the paramedics. If the same situation happened tomorrow and I didn't have our nurse standing next to me I would be calling the paramedics before consolting our nurse. But in this situation the nurse happened to be standing next to me when we first discovered the problem. So that is why the guy didn't get a trip to the ER. Not my call I was over riden because all of our medical decisions are left to the medical staff (when they are in).


Thanks for the responses all I appericate them.

swatsurgeon
10-04-2004, 08:02
in the initial description it stated he was seen/treated at a hospital...that's what threw me; have to differentiate the levels of care provided in a non-trauma center hospital vs. a trauma center hospital. Agree then that the pressure on the wound typically would be enough but significant bleeding to the volume described usually would push for a return to the Trauma center for a closer look...or risk the re-re-re-re bleeding episodes that will end up frustrating the hell out of this guys babysitters.
T-2

RLynch
10-23-2004, 20:52
The initial treatment of a pneumothorax involves the determination of stability of the patient. Considerations for treatment must be individualized based on the origin and degree of stability. If the patient is relatively asymptomatic with the small spontaneous pneumothorax, inpatient or outpatient observation without intervention may be appropriate. Pleural space air is gradually reabosorbed supplemental oxygen increases the rate of reabsorption. This is all based on the percentage of the pneumothorax. A would always call EMS I would never want a prisoner to die on my watch. And yes those wounds could be sutured.

RLynch
10-23-2004, 20:56
A mild cough give the DX of pneumothorax away without xrays

RLynch
10-23-2004, 21:00
The bump under the chest could be subcutaneous crepitus, air or subcutaneous emphysema from the wound

Doc T
10-25-2004, 19:26
It would be interesting to know what the trauma center did to work him up on initial presentation...

As stated prior, SW in this area need further workup. Typically if they are hemodynamically stable the workup involves an upright CXR to evaluate a pneumo or hemothorax and an echo is obtained to look at the pericardial sac for fluid as a tamponade could be occuring without any symptoms or signs until it is too late. A repeat xray should be obtained after 3-6 hours depending on who you read to look for a slowly occuring leak and subsequent pneumo. In my experience, most patients with pnemothoraces do not cough until the pneumo is evacuated but everyone's cases are different.

If the patient had been unstable a trip to the OR would have been in order for either a sternotomy or a pericardial window to look and see if fluid exists around the heart.

Regardless, the patient should have returned to the trauma center to be re-evaluated after bleeding as its better to assume the worst and find nothing than to assume the best and have a dead patient...

I disagree with your nurse that the patient should have stayed at your facility after the above mentioned events. Sometimes bad things happen slowly and if he didn't stay long at the trauma center subtle clues could be missed.

just my 2 cents....

doc t.