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Gunshot wounds

Gunshot wounds. Warning: This presentation has extremely graphic pictures!. Richard P. Kness, EMT- P. Objectives. After this lesson the student will be able to: List scene safety issues Describe procedures to protect crime scene evidence recognize signs and symptoms of a gunshot wound

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Gunshot wounds

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  1. Gunshot wounds Warning: This presentation has extremely graphic pictures! Richard P. Kness, EMT- P

  2. Objectives • After this lesson the student will be able to: • List scene safety issues • Describe procedures to protect crime scene evidence • recognize signs and symptoms of a gunshot wound • categorize treatment for gunshot wounds based on location and travel of bullet • Document scene and care provided

  3. Gunshot Wounds Injuries created by medium or high-velocity weapons

  4. SceneSize-Up

  5. Overall Assessment Scheme Scene Size-Up Initial Assessment Trauma Physical Exam Vital Signs & SAMPLE History HOSP Detailed Physical Exam Ongoing Assessment

  6. Scene Size-Up Determining any threats to your own safety or to the safety of your patients or bystanders, to determine the nature of the call, and to decide if you will need additional help

  7. Scene Safety

  8. Scene Safety Protect bystanders (prevent them from becoming patients). Never enter an unsafe scene. Make scene safe or call for someone who can. The “Danger zone” may be far reaching when a gun is involved

  9. Scene Violence Use scene clues: Fighting Loud voices Alcohol/drug use Unusual silence Prior experience

  10. Crime Scenes and Violence Every Gun shot wound is considered a crime scene until investigated by Law Enforcement

  11. Crime Scenes and Violence Work with Law Enforcement: (Don’t be a “mobile evidence destruction unit”) • If possible do not disturb evidence: • Weapons • Clothing • damaged doors, or windows where entrance was made • Blood pools or tracked blood • Other considerations?

  12. Body SubstanceIsolation

  13. Body Substance Isolation • Anticipate the need for BSI. • Always have BSI equipment available. • Use appropriate equipment to prevent exposure. • Gloves • Face and eye protection • Gown

  14. Assessment of the Trauma Patient

  15. Overall Assessment Scheme Scene Size-Up Initial Assessment Trauma Physical Exam Vital Signs & SAMPLE History HOSP Detailed Physical Exam Ongoing Assessment

  16. YesPerform a rapid assessment. NoPerform a focused assessment. Assessing the Trauma Patient Is there a significant mechanism of injury?

  17. Mechanism of Injury

  18. Mechanism of Injury Gunshot wounds

  19. Mechanism of Injury The physical event that caused an injury (knife wound, gun shot wound, motor vehicle accident, etc.)

  20. Mechanism of Injury: Penetrating Trauma • Velocity • Low velocity–knife • Medium velocity–handgun, shotgun (generally less than 2,000 feet-per-minute) • High velocity–rifle (generally greater than 2,000 feet-per-minute) • Body region penetrated • Exit wounds

  21. Wound ballistics (Kinematics)

  22. Wound Ballistics: Medium and High velocity wounds • Factors that contribute to tissue damage include: • Bullet size: The larger the bullet, the more resistance and the larger the permanent tract • Bullet deformity: Hollow point and soft nose flatten out on impact, resulting in a larger surface area involved.

  23. Wound Ballistics: Medium and High velocity wounds • tissue damage continued: • Semijacket: The jacket expands and adds to the surface area • Tumbling: Tumbling of the bullet causes a wider path of destruction • Yaw: The bullet can oscillate vertically and horizontally (wobble) about its axis, resulting in a larger surface area presenting to the tissue.

  24. To what is cavitation (shock wave) related? Gunshot Wounds: Cavitation

  25. Entrance and exit wounds Gunshot Wounds

  26. Wound Ballistics: Medium and High velocity wounds • The wound consists of three parts: • Entry wound: Usually smaller than the exit wound • Exit wound: Not all gunshot wounds will have exit wounds and on occasion there be multiple exit wounds due to fragmentation of bone or the bullet. Generally the exit wound is larger and has ragged edges.

  27. Entrance and Exit Wounds

  28. Wound Ballistics: Medium and High velocity wounds • The wound consists of three parts: • Internal wound: Medium-velocity bullets inflict damage primarily by damaging tissue that the bullet contacts; High-velocity bullets inflict damage by tissue contact and transfer of kinetic energy (the shock wave producing a temporary cavity) to surrounding tissues

  29. Mechanism of Injury: Penetrating Trauma

  30. Gunshot wound trauma injuries

  31. Penetrating Trauma Injuries • Head: The skull is a closed space, thus presenting some unique situations: • The shock wave has no place to go therefore the brain tissue can be compressed. • If the forces are strong enough the skull may explode from the inside out. • A medium velocity bullet may follow the curvature of the interior of the skull. This path can produce significant damage

  32. Punctures/Penetrations(Gunshot wounds)

  33. Punctures/Penetrations (Gunshot wounds)

  34. Penetrating Trauma Injuries • Thorax: Three major groups of structures inside the thoracic cavity must be considered in evaluating a penetrating injury to the chest: • Lungs: Less dense tissue so injuries are generally from the bullet tract and less so from a shock wave. Serious injuries include a pneumothroax or hemothorax

  35. Penetrating Trauma Injuries • Thorax: • Vasular: Blood and muscle is more dense than lung tissue, therefore it is more susceptible to shock waves in addition to the bullet track. • Injuries include damage to the aorta and the superior vena cava as well as injury to the heart muscle.

  36. Penetrating Trauma Injuries • Thorax: • Gastrointestinal: The esophagus is located in the thorax and may be injured by the bullet track • Injuries include damage to the esophagus as well as spilling any contents into the thoracic cavity which can lead to infection.

  37. Punctures/Penetrations(Gunshot wounds)

  38. Penetrating Trauma Injuries • Abdomen: The abdomen contains structures of three types: Air filled, solid and bony. • Gastrointestinal: The majority of the GI system is located in the abdomen. Most of the GI tract structures are considered to be air filled. • Injuries include damage to the GI system structures as well as spilling any contents into the abdominal cavity which can lead to infection.

  39. Penetrating Trauma Injuries • Abdomen: • Solid organs: The solid organ of the abdomen are very susceptible to direct injury as well as injury from the shock wave. • Injuries include direct and shock wave damage to all of the solid organs such as the liver, spleen, pancreas, and the kidneys in the retroperitoneal space. Let’s not forget about the bladder, uterus, ovaries, gall bladder, and major blood vessels such as the vena cava and the aorta.

  40. Penetrating Trauma Injuries • Abdomen: • Bones: The pelvis is a very vascular organ. Fracture of the pelvic due to a gunshot wound can lead to major blood loss • Injuries are generally limited to direct bullet track damage. The bone fragments may become secondary missiles and cause additional damage.

  41. The ultimate in fragmentation is created by shotgun wounds Shotgun Wounds

  42. Penetrating Trauma Injuries • Muscles, peripheral nerves and blood vessels, connective tissue, skin and bones: • All of these tissues may suffer direct injury or shock wave injuries. • Injuries may include: tissue loss, bleeding, and loss of function,

  43. Open Wound

  44. Rapid TraumaAssessment

  45. Rapid Trauma Assessment Head Neck Chest Abdomen Pelvis Extremities Posterior

  46. = = = = Burns Tenderness Lacerations Swelling B T L S Inspect and Palpate for DCAP-BTLS = = = = Deformities Contusions Abrasions Punctures/Penetrations D C A P

  47. Significant Mechanism of Injury Assess baseline vital signs. Obtain SAMPLE history. Consider requesting ALS. Reconsider transport decision.

  48. SAMPLE History

  49. If No Significant Mechanism of Injury • Reconsider mechanism of injury. • Determine chief complaint. • Perform focused physical exam based on: • Chief complaint • Mechanism of injury

  50. Detailed Physical Exam

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