New Case

[swatsurgeon]

For 18D and the like and PA's....doc's hold your fingers/tongues for now:
Small arms fire. Soldier takes a round above the armor in the neck (we hope not). Able to function and return fire....seeks cover 25 feet away. Medic happens to be right there seeking the same cover:
Air bubbles from hole. Able to breath with LITTLE difficulty, can speak but with some difficulty from blood, no obvious expanding hematoma. Some pain in neck. [see picture].

Discuss your initial treatments and what is going through your mind: overall, how are you going to handle this case as presented from area of cover through evac and forward most medical facility.
We'll then pick it up from there.

ss

[desertmedic]

First thought is a tegaderm or similar occlusive dressing to seal the wound. Is there an exit wound? Would be prepared to intubate or cric. C-spine control would be nice but not necessarily plausible in this setting. Undecided on pain meds weighing Px level vs. anticipated level of respiratory distress. An access line or two would be nice depending on time/present location, if volume replacement is needed going with hypotensive resuscitation. Just my thoughts,

Desertmedic, NREMT-P

[swatsurgeon]

Originally Posted by desertmedic

First thought is a tegaderm or similar occlusive dressing to seal the wound. Is there an exit wound? Would be prepared to intubate or cric. C-spine control would be nice but not necessarily plausible in this setting. Undecided on pain meds weighing Px level vs. anticipated level of respiratory distress. An access line or two would be nice depending on time/present location, if volume replacement is needed going with hypotensive resuscitation. Just my thoughts,

Desertmedic, NREMT-P

No second wound (i.e. potential exit). Pain tolerable and descried as midline as well as to the right and 'behind' the trachea. Palpation of wound area puts the hole through the thyroid cartilage, no palpable hematoma, bullet, etc.

Patient awake, alert, still in the fight since evac not for 30 minutes.

So, Desertmedic, you placed an occlusive dressing and his neck begins to develop subcutaneous air and he doesn't like the full feeling he's getting and rips off your dressing....feels better without it he says. He lets you start a 16G IV site but no way to hook him up to IVF right now, he's not in distress, just pissed he's been shot, not light headed, not any more tachycardic than you are.

What is happening and what do we do for the next 30 minutes.

ss

[desertmedic]

Thought there might be a problem with subq air. If he isn't in any distress monitor airway and CV state, will sit on those. Still have concerns on potential c-spine injury, but if he is still in the fight should he be taken out of it? Not sure about that. Don't see a need for imediate pain management at this moment. Standing by to step on myself some more,

Desertmedic

[swatsurgeon]

Since this one didn't generate much interest except desertmedic........
patient makes it uneventfully to forward field hospital and gets xrays.
On exam, air from anterior wound, no other wound, no carotid bruit.
Patient getting anxious and still coughing up blood, so intubated.
See xrays: paper clip over entrance wound to assist in determining trajectory (left side of paperclip over wound) .
Next Step?

[trailrunner]

Before we move on to the hospital and treatment, etc., per, the first 30-45 min of this situation. What is the appropriate immediate response?

I am not medically qualified as a first responder, but I am curious on the right way to initial respond to this as someone who would want to help until a medic is found or transport to hospital is possible. I know more medical training is in my future to be able to do this "right enough" until better care is found.

As I understand the situation... adrenaline is kicked into high gear and possibly blocking any responses to pain, solider has to stay in the fight for the moment (and wants some heavy duty reprisal), rejecting closing up the wound because of build up and ease of breathing at the moment...

Am I to understand if the soldier can "work"... Let them work. The hospital will take care of the rest once the soldier is there? My part would be to make sure they get there pronto!

A couple of things come to mind after seeing this problem...

No exit wound, what stopped it? What is broke or near to breaking that I can't see and the soldier can't feel at the moment? How do I keep this soldier in the positive and not heading toward the negative?

The more you know...

[SeanBaker]

First off, thanks for posting a new case S/S.

At the EMT-B / CLS level...

1. Return fire; eliminate the threat.
2. Palpate / expose wound / look for secondary injury
3. Instruct pt to hold still, possibly lie down (METT-TC - cervical immobilization; philly collar is coming)
4. Depending on what I'm carrying, either insert a lubed (to seal) child-size ET-tube (small NPA?) through thyroid cartilage to secure airway OR tape kerlix to entry site w/ inspection/change of dressing q. 5m (absorb blood)
5. Apply philly collar
6. Evac - Urgent Surgical

What I'm thinking:

To have not exited the neck, projectile is a fragment, a ricochet, or lodged in the C-spine. The first two options provide a high risk of additional damage with movement d/t sharp edges and unknown location within the neck, while the third may be the most dangerous with potential for spinal cord injury either directly, d/t bone / bullet fragments or swelling. Airway has to be controlled. A lubed tube through the point of injury will provide a seal against additional bleeding into the airway as well as provide a measure of control against tissue swelling - situational intubation of a conscious casualty is a no-no at my level and doesn't seem to be indicated for anyone outside the hospital unless he codes. The alternative - kerlix taped to the injury site - will absorb the majority of the fluid (preventing it from entering the airway) while not causing the sub-cut air referred to previously. Philly collar is a necessity d/t injury site (civ. doctrine would also dictate backboarding, though that doesn't seem realistic for the situation).

I'm looking to learn, so please tell me if / how badly I've gone wrong...

[sofmed]

I hope you guys don't mind, but I'd like to resurrect this one. I haven't had the opportunity to deal with something like this (hope I don't have to) and I would like to hear more on what the proper tx and followup would be.

Mick

[linedoc]

As for the initial portion of this scenario my course of action medically would be:


1. Explain to the soldier why I am taking him out of the fight.

2. C-collar, at this point I don't know where the bullet/fragment is. Try to minimize potential for further injury.

3. Secure airway with a NPA through wound, and verify air exchange.

4. Get IV access, saline lock.

Hold PN meds as to not obscure mental status. Monitor vitals, mental status and obtain a good NV exam. Reasses airway and reassure PT.

Hold tight for dustoff.

[sofmed]

Originally Posted by linedoc

As for the initial portion of this scenario my course of action medically would be:


1. Explain to the soldier why I am taking him out of the fight.

2. C-collar, at this point I don't know where the bullet/fragment is. Try to minimize potential for further injury.

3. Secure airway with a NPA through wound, and verify air exchange.

4. Get IV access, saline lock.

Hold PN meds as to not obscure mental status. Monitor vitals, mental status and obtain a good NV exam. Reasses airway and reassure PT.

Hold tight for dustoff.

Would you use anything to guarantee a good seal around the NPA you've stuck in the wound...vasaline impregnated guaze, etc, or simply leave it as it is. I only ask because at SOFMS-P I was taught when dealing with a chest tube to use the impregnated guaze to ensure no air could infiltrate, either in or out around the tube. ??? I'm concerned about the subq being a problem and would like to know more, as I stated previously that I haven't had to deal with any neck wounds of this nature before.

Thanks!

Cheers.

Mick