Some Words about Initial Treatment of Traumatic Injuries When Trauma Level Medical Care is Distant or Otherwise Overwhelmed.
By Jane-Alexandra Krehbiel BS ES RN
Most of us would like to believe that we have stocked and supplied adequately in order to meet our family or groups needs in the event of an illness or injury which coincidentally occurs during a natural disaster or other national emergency. Some of us have prepared elaborately for such events. We would also like to believe that RN, EMT, CCRN or other certifications have prepared us to render excellent care under adverse circumstances.
Largely, the survivability of injury and trauma depends greatly on the general condition of the patient you have. A man of 45, in excellent health, whose tractor rolls over him, crushing his leg has a better chance of survival than does a person with a prior medical history, or who takes regular medications, etc. Your male patient of excellent health may survive shock better,tolerate diminished blood flow to core organs, and survive pain that you will be limited in your ability to control.
The focus of this particular article though with regard to traumatic injuries this week though is gunshot wounds. A number of you have asked for guidance and strategies in the initial treatment of gunshot wounds in the event that medical systems are known to be overwhelmed. Remember that all physicians and nurses must report gunshot wounds,and therefore most of us will be unwilling to discuss the management of such wounds. Even to a normal emergency room, gunshot wounds can bring surprises. There remains a fairly high rate of mortality for gunshot victims within the first 24 hours,even when they ARE managed by a competent ER. The amount of damage done to a patient depends largely on several factors, first, the size and type of the projectile, the speed by which the projectile entered the body, and the location of the wound itself. In the most general of terms,the larger the gun the larger the hole. Very generally, rifle wounds cause more damage than handguns, and rounds with a metal jacket, particularly copper, do more damage. Remember that some rounds may be in and out, and others shred and spread. Even with x-rays and CT scan,there can be damage that was not anticipated. (And requires splenectomy or other surgery to preserve life) Remember also that 22s especially, on entering the body, tend to bounce around, and despite being a small round can lacerate a lot of internal organs before exiting or more likely,coming to rest. It’s important to realize that no two gunshots are identical, even when you think you know the entrance and exit wounds. No one really knows what that round did internally prior to exiting.
For these reasons, recommendations generally are that you contain the bleeding, using universal precautions* to protect yourself and others from blood exposure, and begin to transport that patient to an open and equipped emergency room within ten minutes of the injury occurance. You should call 911. Generally an ambulance transport is best, as many can start IVs, for venous access to give drugs, have oxygen, call ahead for supplies and speak with a physician directly from the ambulance. These patients may not be aggressively hydrated because it is often felt that aggressive hydration in the presence of a major wound enhances bleeding. Many of you however, will be in remote locations and will be transporting a patient yourself. If you do this, there is value in transporting the patient to a waiting ambulance in another location. (You would be moving them a shorter distance before you had the benefits of an ambulance transport) Certainly, a Shock Trauma ER would be best, but a normal ER which stabilizes and perhaps transports after may be the best choice given your location. Remember that most Shock Trauma Centers can boast only a 5% mortality rate for a gunshot wounds which enter the abdomen, whereas a home treated person likely has a 95% mortality rate for the same injury. If the wound is in the chest, place clean plastic over it to help maintain inflation of the lung behind the wound. If this worsens your patient’s breathing remove it. Use your cleanest or sterile gauze in direct contact with the wound, and then apply additional cloth, gauze or absorbent material on top of that to contain bleeding. Do not give anything to eat or drink including alcohol as this can cause vomiting and aspiration with death when this patient enters an operating room and is anesthetized for repair. Generally, we elevate legs for shock,but in the event of a gunshot wound in the abdomen, back, or chest, this would be unwise as it may increase the speed of blood loss, so do not elevate legs.
While your patient is en route, someone needs to notify the receiving hospital of exactly what is coming with as much information as you have. This will allow them to have the right types of surgeons, right equipment, an OR, and lots of O negative blood and plasma expanders ready. I once called ahead and had a hand surgeon ready to do microsurgery on my eldest son who had a serious wood shop injury. Also tell them the patient’s allergies particularly to drugs, if known.
Following the initial ER assessment, and initial OR repairs, these patients require intravenous antibiotics. The only reason that so many patients survive gunshot wounds today is that intravenous antibiotics can attain a blood level that oral antibiotics simply cannot. Remember that anyone even grazed by a bullet in the Civil War often died,and this difference is largely our modern INTRAVENOUSLY formulated antibiotics.
There are many things that we can do at home while talking to a physician on the phone. Successful management of gunshot wounds is not generally one of them. To review, 1. we need to protect ourselves and others on scene from a.) getting shot also b.) exposure to blood at the scene. 2. Call 911,to meet reporting requirements under law,and to get our transport ambulance or helicopter. 3. try to limit bleeding while keeping patient calm. Apply plastic to chest wounds to treat potential sucking chest wounds. 4. Have ambulance pick up and find out where they are going exactly. 5. Call ahead to that hospital to tell them what is coming and to convey allergies or any other health information about your patient they may need. 6. Travel to hospital to answer law enforcement questions and to ensure care for your patient. Accompanied patients ALWAYS receive better care than unaccompanied.
Handle your firearms safely, lock them up when appropriate,and teach young people safe handling firearm techniques, not simple avoidance of firearms. When it comes to gunshot wounds, prevention is always preferable to treatment.
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Those who wish to be trained in Tactical Treatment of Firearm Wounds may wish to take a course created by Anthony M. Barrera MD