Adonis Posted February 16, 2008 Posted February 16, 2008 ALS Call to an armed robbery. 35yr Male GSW to neck. Police at scene. On arrival you find the pt slumped to his left side in a chair next to an open safe (Blood and cash all over the Floor) Pt is unresponsive. Fire is holding pressure on the wound. you take over quick assessment : Res 12, pulse 100, bp 80/40 you noticed bubbles from the neck wound.
Niftymedi911 Posted February 16, 2008 Posted February 16, 2008 Call Trauma Alert Immediate C-spine, occlusive dressing with pressure (Ace wrap), oxygen via BVM insert OPA, backboard, rapidly place in truck. Grab a FF, jump in the truck. Once in truck and enroute to hospital, intubate, 2 large bore IV's, secondary assessment, call report and pray he makes it.
AnthonyM83 Posted February 17, 2008 Posted February 17, 2008 Pretty similar to above, though I wouldn't use ace wrap...or any kind of wrap....Probably a heck load of 4x4's would work best here.... I would do a rapid full-body assessment while they're placing him on c-spine. What's his mental status? O2 Sat? How much blood loss? Does bleeding become controlled with pressure? How is his airway?
Just Plain Ruff Posted February 17, 2008 Posted February 17, 2008 WAIT WAIT WAIT - you are gonna put an ace wrap on a neck gsw??? Please explain your rationale for putting a constrictive dressing on a neck wound?
ccmedoc Posted February 17, 2008 Posted February 17, 2008 Tourniquet..or a belt to hold the ace wrap in place.. :wink:
Richard B the EMT Posted February 17, 2008 Posted February 17, 2008 I'm thinking a "pressure dressing" on top of the obvious injury site as it is wrapped. I might improvise by putting 2 kling rolls on either side of the throat to prevent pressure on the windpipe, and perhaps another one on the opposite side of the neck from the GSW alongside the carotid artery, for the same reason. A possible alternate is, manually maintaining direct pressure on the GSW site. This is just off the top of my head. Any other suggestions, particularly from BLS (including requesting ALS intervention for replacement of fluid)?
DwayneEMTP Posted February 17, 2008 Posted February 17, 2008 How much blood does there appear to be? What does the pt's skin look like? How big are the bubbles coming from the wound? We may be jumping the gun a bit with arguing the type of dressing if this man's larynx is involved. Rapid transport is a no brainer, stopping the bleeding is a no brainer, but if there are large bubbles coming from his larynx upon expiration, what do you suppose is happening upon inspiration? I need to see the location/anatomy involved in the injury, but at this point it sounds as if I'm going to intubate at the same time they are putting him on the board. ABCs. With the above description it sounds as if A/B could be in serious jeopordy, I believe I'll address those while someone gets a couple of good IVs and fire is packaging for transport. What was it we learned in Basic class about delivering a well bandaged/splinted corpse? And I'm not on board with the ACE bandage...I'm thinking a full diameter pressure dressing is a bad idea in a neck injury. We're going to have someone bagging on the way in, they or someone else can manage the wound manually (certainly an occlusive dressing, regardless of what we decide to use for bulk outside of it), unless we have a 3 hour transport or the like... More when we get further informtion. Dwayne
Mateo_1387 Posted February 18, 2008 Posted February 18, 2008 Where exactly on his neck is he shot? are there clear enterance and exit wounds? If airways is obstructed I want to clear it and possibly intubate. What about lung sounds? Also would want to do a trauma exam to look for other gsw's. will want to control bleeding by at least direct pressure and possibly an occlusive dressing. Start an IV. Backboard the patient. Give high flow O2.
mobey Posted February 18, 2008 Posted February 18, 2008 I'm thinking a "pressure dressing" on top of the obvious injury site as it is wrapped. I might improvise by putting 2 kling rolls on either side of the throat to prevent pressure on the windpipe I would grab a firemonkey to keep manual pressure on the wound. I am unsure about the above statement. Should we be worried about applying pressure to the carotid arteries or in/ex jugulars? I don't know I am not familiar enough with any problems that may come of this. (if there are any) Occlusion? Vagal responce? I dunno just thinkin out loud.
DwayneEMTP Posted February 18, 2008 Posted February 18, 2008 I would grab a firemonkey to keep manual pressure on the wound. I am unsure about the above statement. Should we be worried about applying pressure to the carotid arteries or in/ex jugulars? I don't know I am not familiar enough with any problems that may come of this. (if there are any) Occlusion? Vagal responce? I dunno just thinkin out loud. Mobey, I love your posts man. Don't always have to be right, fine with being wrong if you can learn from it...That's pretty smart, and pretty brave. A quick thought on your question. I'm thinking we have a systolic b/p of 80 now. We currently believe it takes between 80-90 mmHg to perfuse the brain, so we're already treading water in that respect. Let's say it takes 30 mmHg of pressure to stem the flow of blood for this wound (just pulled that out of my rear). Have we then reduced the pressure for cranial perfusion to 50 mmHg or so? I'm not sure if it would do so or not...perhaps after the the pressure built up behind the occlusion the original pressure would be returned more or less? I'm not sure, physics is on my list to take after I'm done with class. But let's take it a step further. If we must monitor our interventions, how would we decide if we had created this pressure differential or not? We can't base it on cranial b/p (well, could we do so with MAT calcs after we've added the artificial occlusion?), can't monitor it based on LOC as our patient is unresponsive. So based strictly on the assumption that we can't verify effectiveness, nor monitor the intervention for creating a negative outcome, would we choose not to use it on these criteria alone? Plus, if we have the hands available, do we want to attempt to explain to those down the line our choice to apply a band around the neck even if WE KNEW FOR CERTAIN that it wouldn't increase morbidity/mortality? Like you, I don't know for sure...just thinking out loud... Dwayne
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