Shotgun hit to back

[Sdiver]

23 year old found face down on the street. Initially semi-responsive, awakens more when you speak to him. States he was walking down the street when a car drove by, he heard a loud “Bang”, felt a pain in his back and woke up on the ground. Complaining of severe pain to the back, some numbness in his arms and tingling in his legs. Mild SOB. Police are On Scene, FD Rescue has arrived prior to you and placed him on a NRB at 15L. SCENE IS SECURE!!!

What you see is what you have.

Level 1 trauma Center is 35 min away. Helo has a 12 min Lift time and 21 min Flight Time.

Pulse: 127
BP: 78/32
Spo2 91% on 15 o2 via NRB by FD
RR 11 Shallow, unable to really hear fields well
GCS 13 at present.
HEENT- Abrasions to forehead, hematoma over left eye.
Pupils- Pearl, 2mm slow to react
Neck- Denies pain, no obvious trauma
Chest- Front = CLR
Lungs- Difficult to hear, poss diminished bilat
Back- AS you see it, MOD-Severe bleeding
Pel- CLR
EXTREM- Small penetrating wound to backsides of upper
Neuro- Some numbness to arms grips equal but weak, tingling to legs with good movement

What is your treatment going to be?
Any special concerns or precautions?
What will your transport decision be?

[swatsurgeon]

TX:

O2 high flow
C Spine
IV NS x 2 en route use at least one blood Y
Rapid transport via ground to nearest trauma center. (if MD is on helo might go that way.)

Possible chest decompression and or chest tube depending on scope of practice as warranted by Sx ie JVD tracheal deviation, decreasing lung sounds etc etc

Pt may have spinal injury and or neurological shock. Also possible hypovolemic shock. Possible hemo/pnumo thorax.

Pt lost conciseness and abrasions on head so possible closed head injury or possible pellet in head/brain. (I'v seen bullets do weird and unpredictable things)

Long story short this guy needs a surgeon ASAP and at best in the field you might be able to relieve a chest hemo and or pnumo thorax to buy him some time.

Someone said "need a surgeon".........:)
great case, no helo and what is the transporting person going to do if
1) paramedic level?
2) EMT-I or B
Cant say possible, what are you going to definitely do

think it through...

[11Ber]

1) Activate Helo launch

2) Seal up that backside with a gang of Hyfins

3) Bi-lat 14g x 3.25" Needle drops on the mid-ax line not mid-clavicular...probably going to produce some blood but then at least we know.

4)500cc Hextend via 18g or 16g to see if he is a responder or if I have bleeding in the box

5) Wouldn't run O2 or C-Collar. I have read and believe several studies pointing to the toxicity/lethality of O2 in trauma situations and C-collars causing injury. 91% O2 Sat is concerning but dude just got shot in the thorax; it isn't a quality of O2 being brought in problem, it's a he is having a failure to exchange due to blood in his plueral space.

[Sdiver]

Helo is OUT .... 12 min lift time, 21 flight time to my local, 10 min on scene time, plus another 21 min flight back = 64 min total time.

This is a load and go.
Do treatment in route.

Apply c-collar for c-spine precaution, but I would not board. If anything I'd use a scoop for any spinal immobilization, but seeing that the wounds are to the back, I would need to be able to get to them as needed.

Apply several occlusive dressings to those wounds in the upper thorax. Others would get trauma bandages to control bleeding.

Continue O2, possibly decreasing amount to 10L or enough to keep reservoir bag inflated.

Establish at least 2 IVs.
1st would be NS attached to blood pump 14 or 16 gauge angio. Bolus fluid as need to keep systolic BP above 90.
2nd IV, NS or possibly buff cap for med administration. No smaller than an 18 gauge (14, 16, 18)

If peripheral lines cannot be established, I would then establish IOs.

Be aware of Beck's Triad (low arterial blood pressure, distended neck veins, and distant, muffled heart sounds) due to possible cardiac tamponade. It would be difficult to see the neck veins due to the c-collar, but if the other two are present, I would consider removing the collar to observe the neck.

Be aware for possible pneumothorax, hemothorax or comination of both, hemopneumothorax.

As a basic, (soon to be Advanced) there's not much I can do to treat the above conditions, but I will have called ahead for possible ALS intercept. I would also consider if there are any hospitals along our route that at least were Level II, then at least we could get in there and let the MDs get the Pt. stable and then call in the Helo for air transport to Level I.

If no hospitals or ALS are available, then I would continue to monitor Pt. keeping systolic BP above 90 and O2 sats at or above 90 as well.

If Pt. has LOC, consider advanced airway (King tube or Combitube), keeping airway established. Apply AED pads, in case Pt. looses pulse, I'd have pads in place as needed.

[11Ber]

Thats what I get for not doing math. I added flight time total to 32...forgot about the damned return flight.

Brush Okie - As for fluids, Hextend is the current TCCC recommended fluid in the absence of FWB or blood products and signs of hypovolemic shock. You can look the protocol up but it is 500cc bolus up to 1L total. Since I am running this in my mind as an 18D I go with the 500 of Hextend. Not so much to cause a huge shift in electrolytes but enough to give his BP a boost. Monitoring blood pressure will let me know if I have bleeding in the box and then we have bigger issues.

I have argued this several times with a general physician/professor in my college program because he still recommends high flow O2 and 2L NS. I have presented the studies I have found with no effect. I will put several of the O2 studies below.

As for C-Spine...nothing tells me he has C-spine issues. Several years ago I sat on a lecture by a doctor from Baylor on the history of and issues with the C-Collar. It was introduced into emergency medicine with no studies proving either its need or efficacy. He and his colleagues have studied it in depth and found multiple issues with its use. The one that sticks out is spinal cord death due to strangulation from being stretched in the C1-C2 region. I will also put that below.

Again, I am only looking at this from the eyes of a SF Medic not an EMT or paramedic. Hopefully this stimulates some good discussion.


C-Collar: https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=4&cad=rja&ved=0CE8QFjAD&url=http%3A%2F%2Fwww.ncbi.nlm.nih.gov%2Fpubmed%2F2 0093981&ei=ZDV9UeOALMHw0gGljICICQ&usg=AFQjCNGgabK2_FxoH039f7tEGKLy3aQkHw&sig2=qAzmBWyjgwoINgovQh3rjw&bvm=bv.45645796,d.dmQ

Pre-Hospital O2 in trauma: http://www.ncbi.nlm.nih.gov/pubmed/15379072

TCCC - http://www.naemt.org/Libraries/PHTLS%20TCCC/TCCC%20Guidelines%20120917.sflb

[MR2]

Could the ongoing insistence on the use of c-collars have anything to do with our litigious society?

[Patriot007]

91% O2 Sat is concerning but dude just got shot in the thorax; it isn't a quality of O2 being brought in problem, it's a he is having a failure to exchange due to blood in his plueral space.

What pulmonary physiologic phenomenon are you describing?

Is there no role for high flow oxygen for treating patients with this state?

[98G]

Thats what I get for not doing math. I added flight time total to 32...forgot about the damned return flight.

Brush Okie - As for fluids, Hextend is the current TCCC recommended fluid in the absence of FWB or blood products and signs of hypovolemic shock. You can look the protocol up but it is 500cc bolus up to 1L total. Since I am running this in my mind as an 18D I go with the 500 of Hextend. Not so much to cause a huge shift in electrolytes but enough to give his BP a boost. Monitoring blood pressure will let me know if I have bleeding in the box and then we have bigger issues.

I have argued this several times with a general physician/professor in my college program because he still recommends high flow O2 and 2L NS. I have presented the studies I have found with no effect. I will put several of the O2 studies below.

As for C-Spine...nothing tells me he has C-spine issues. Several years ago I sat on a lecture by a doctor from Baylor on the history of and issues with the C-Collar. It was introduced into emergency medicine with no studies proving either its need or efficacy. He and his colleagues have studied it in depth and found multiple issues with its use. The one that sticks out is spinal cord death due to strangulation from being stretched in the C1-C2 region. I will also put that below.

Again, I am only looking at this from the eyes of a SF Medic not an EMT or paramedic. Hopefully this stimulates some good discussion.


C-Collar: https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=4&cad=rja&ved=0CE8QFjAD&url=http%3A%2F%2Fwww.ncbi.nlm.nih.gov%2Fpubmed%2F2 0093981&ei=ZDV9UeOALMHw0gGljICICQ&usg=AFQjCNGgabK2_FxoH039f7tEGKLy3aQkHw&sig2=qAzmBWyjgwoINgovQh3rjw&bvm=bv.45645796,d.dmQ

Pre-Hospital O2 in trauma: http://www.ncbi.nlm.nih.gov/pubmed/15379072

TCCC - http://www.naemt.org/Libraries/PHTLS%20TCCC/TCCC%20Guidelines%20120917.sflb

I saw the Baylor and Israeli studies as well. Really makes you think twice. Would love to see more published on c-collar results. The fluid resuscitation is generating discussion as well, but there at least the indicators could lead you through a logical choice and monitor results. C-collar not so much from the available studies.

[RichL025]

1) Activate Helo launch

2) Seal up that backside with a gang of Hyfins

3) Bi-lat 14g x 3.25" Needle drops on the mid-ax line not mid-clavicular...probably going to produce some blood but then at least we know.

4)500cc Hextend via 18g or 16g to see if he is a responder or if I have bleeding in the box

5) Wouldn't run O2 or C-Collar. I have read and believe several studies pointing to the toxicity/lethality of O2 in trauma situations and C-collars causing injury. 91% O2 Sat is concerning but dude just got shot in the thorax; it isn't a quality of O2 being brought in problem, it's a he is having a failure to exchange due to blood in his plueral space.

No issues with this except for #5.

Even with a ptx or htx, high flow O2 will increase the diffusion of O2 across the alveoli. Addressing the cause of his poor oxygenation is probably more important, but maximizing his FiO2 is still an intervention that will benefit him.

[swatsurgeon]

C collar data for penetrating injury is based on "most likely trajectory" that may have caused direct cord/canal injury. Also based on physical assessment ie any focal neuro findings on exam.
98-99% of the time, non direct neck penetrating injury will not cause cord injury (unless posterior midline or 2 wounds to plot trajectory across the vertebral bodies)

No need for multiple chest seals: they are for "open" chest wall injuries and unless he took the blast at close range with disruption of the chest wall, no value to chest seals unless you hear or see air exchanging through a wound....and the chances of that occuring from a distand shot gun blast which this was (no wad injury noted on picture) are slim to none with bird shot size holes.

ss

[frostfire]

What pulmonary physiologic phenomenon are you describing?

ventilation vs. oxygenation. V/Q mismatch

Speaking of the research studies and best practice, I had learned to take what I learned from engineering to medicine, which are trade-offs and baseline/steady state ie. on septic shock resuscitation with levophed, we may kill perfusion to kidney in order to keep perfusion to heart, lung, and brain, and so on.

Case-by-case basis seems to be the paramount approach, which is why every level of treatment is best served with individual's thinking critically. Having said that, we do have algorithm to speed up flow of treatment and justify intervention even when the final outcome is sentinel. I think it's mentioned here before and my trauma/critical care instructor agrees which is we can do 100% right (according to guidelines) and the patient is 100% dead. CYA....CYA....CYA :boohoo

[swatsurgeon]

Hextend......it has a role but for penetrating trauma, blood wins or nothing; Red and yellow can save a fellow, clear can kill at will.
Giving blood and plasma wins the day. IV fluid dilutes the remaining blood, dilutes the coagulation factors that remain and temporarily increases blood pressure which can pop a clot right off its stable position and doesn't hang out long at all.
Give one liter of saline and in 30 minutes only 300mL is intravascular. Which is why we try and preserve what's in the body the best we can.
Hex tend will stay intravascular longer but has no oxygen carrying capability; treating a number to get BP up but to what end???

ss

[frostfire]

Hextend......it has a role but for penetrating trauma, blood wins or nothing; Red and yellow can save a fellow, clear can kill at will.
Giving blood and plasma wins the day. IV fluid dilutes the remaining blood, dilutes the coagulation factors that remain and temporarily increases blood pressure which can pop a clot right off its stable position and doesn't hang out long at all.
Give one liter of saline and in 30 minutes only 300mL is intravascular. Which is why we try and preserve what's in the body the best we can.
Hex tend will stay intravascular longer but has no oxygen carrying capability; treating a number to get BP up but to what end???

ss

ss, thanks for the education as always

[RichL025]

I have argued this several times with a general physician/professor in my college program because he still recommends high flow O2 and 2L NS. I have presented the studies I have found with no effect. I will put several of the O2 studies below.


Pre-Hospital O2 in trauma: http://www.ncbi.nlm.nih.gov/pubmed/15379072


When you use a study to try and justify the way you are practicing, you have to do it cautiously. There are several things you have to consider, of which I will just point out a few here.

Does the study make sense? Is it plausible? Are you really going to withhold oxygen on your patients because of a single database-mining study where no benefit was found? Or is it more likely that the authors were not able to cone down to enough fine detail in the database to identify the patients whom supplemental oxygen helped?

And what if it is only of _minor_ benefit in these patients? Does it cause any harm? (Anyone who is getting ready to repeat that old wives tale about COPDers please sit down and be quiet). If an intervention is cheap, does not cause any harm, and _might_ contribute some benefit, then you would be quite foolish to discard it based on a single retropective study published in a third-tier journal...

Another question you have to ask when practicing "evidence-based medicine" is: does this data apply to MY patient? I will leave this point as an exercise for you - please go back and look at that abstract you linked to, and see what patient population the author explicitly said his conclusion does not apply to....

[swatsurgeon]

As RichL025 Appropriately stated, not every study fits your patient. Very elegant mathematical studies have shown that no one devised protocol or evidenced based medicine study can apply to 100%of a study population. The best that has been achieved is around 85%. Therefore, all modern studied are good for the majority but not the entire population, so for ~15%c you have to "think" and not just follow a protocol. As far as oxygen, some of us don't and can't carry it on deployment, it's back in a warm/cold zone, And there is 21% in the air so plenty for what I need it for. Remember, the only reason for supplemental oxygen In a shock state, the tissues are not meeting their metabolic demands and hypoxia is a factor, so to improve this we provide supplemental O2. When in a hot zone not one person I know worries about supplemental O2, there are far greater concerns.

[Patriot007]

ventilation vs. oxygenation. V/Q mismatch

Right, specifically intrapulmonary shunt, as 11ber was referring to. It is true in a pure shunt that supplemental O2 only increases SPO2 marginally, however since there are likely more variables than a pure shunt it is worth the relative minimal risk of superoxygenation.

There is a good deal of research now looking into how aggressive we should be in the ED and even in the field on O2 titration. Recent data does suggest aggressively titrating FIO2 in many types of patients including TBI and stroke, but these studies don't warrant restriction of high flow oxygen in an unstable patient.