GSW vs Pentrating chest wound

[jjd]

Hi all,

I have a scenario i would like to run past you.

You arrive on scene to find 2 patients.

1 x GSW abdo, no exit wound. Patient is approx 35 years old, weighs roughly 79KG's (sorry not sure how many pounds that is) BP 126/75, RR 25, GCS 12, HGT 4.2 (glucose) , Pulse 78. Slightly diaphoretic.

1 x Penetrating chest wound, stabbed with a 5 inch serrated blade at the second IC space, Mid clavicular line on the left side of his chest. Patient approx 35 years old, weight 79kg's, BP 115/72, RR 32, GCS 12, HGT 4.2, Pulse 89, you notice slight diaphoresis and what could possibly be jugular venous distension. Air entry seems = on both sides as does chest expansion.

Edit: Your ECG and pulse ox are not operational.

Your in an ALS response car and are met at the scene by 2 x BLS in an ambulance. You can only take one patient. Which one would get higher priority and get attention first and what would your treatment be? Your in South Africa where you are registered and considered an indepedant practitioner (in other words there is no such thing as calling medical control and it's your decision in the end)

Edited September 1, 2010 by jjd

[HERBIE1]

Unfamiliar with local protocols, but-

I would give the GSW to the BLS guys, Start a couple large bore IV's(omit this if the BLS guys cannot transport with the IV's) 100% O2, high flow, treat for shock, bleeding control. MAST pants if applicable, treat for shock, and tell them to run like hell..

Why? Because other than large bore IV's, there is nothing more an ALS provider can do prehospitally for a GSW to the abdomen- at least until they arrest. Unclear where that bullet went, or where the damage is.

I would do the same treatment for the SW, but would take this patient because if they do develop a pneumo or tension pneumo, we can decompress that, whereas a BLS guy cannot.

In a triage situation, both patients would be considered reds or critical, so in your scenario, you need to dig deeper and consider the details and make a judgment call.

[chbare]

I assume we are in the role of a B-tech paramedic?

I'd take them both in the ambulance but assume this scenario is so linear that we must choose one or the other? Clearly, the second patient, based solely on the information available, requires immediate intervention. Rapid transport, fluid challenge if needed as a temporary measure and take him to an appropriate medical centre.

Take care,

chbare.

[Kiwiology]

Take patient to hospital; decompress the pneumo and give a small fluid challenge to the GSW should they become indicated, little oxygen if they are hypoxaemic but that's about it.

[FireMedic65]

In the location of the stabbing, it is the same location where you would do a chest decompression. I would put on an occlusive dressing (BLS can treat a sucking chest wound and "burp" the dressing)

The GSW can present with little to no symptoms, aside from a hole in the belly, and the patient may look fine. As we know, the abdominal cavity will fill up and pool A LOT of blood. The patient will be going into shock and we will hardly notice it because there is little blood loss.

As for the stabbing, the location isn't quite as bad, but still pretty serious. There are lots of vessels on the inferior/posterior of those ribs. Having them hit with the knife can lead to serious problems. This patient will need a chest tube most likely, which can't be done in the field.

Like Herbie mentioned, these situations are just that... situational. Keeping calm and looking at the big picture is what is important here (if we are talking BLS or single crew). Using your best judgement and following triage protocols will most likely help you. It is hard to say which patient is more critical without more information.

If it were me, a single crew. I would do the rapid trauma assessment, stabilize best I can, and transport both at the same time and request another unit to rendezvous en route if possible.

[chbare]

If the stabbing is really developing JVD, then we have to assume tamponade. Especially when we consider the location of the injury. This patient may quickly transition to a moribund state.

Take care,

chbare.

[Happiness]

Pretty tough one.

Im sending the SW first with the notification of going right behind them with the GSW.

#2 is already showing signs of a pnumo and A comes before C.

Wow I think that is the simpilest answer I have ever given here

[chbare]

It's not a pneumothorax that concerns me. In fact, that would be much preferred over what we must suspect.

Take care,

chbare.

[jjd]

So the general consensus at the moment is that the SW be transported first based on.... raised JVD, pneumo and the possibility of a tamponade based on the wounds location? Firemedic made a good point that the wound is directly in the same location that a needle decompressionn would be done at. What alternatives do we have to relieve the tension? Would an occlusive dressing make the slightest difference to someone who is already presenting with raised JVD, which as we know present in the late stages of a tension pnuemo.

Sorry if this is a mundane scenario, i'm relatively new to ems and believe participating in a few scenarios would benefit me. The reason i posted this particular scenario is that i have a friend who is a new intern at a provincial hospital. She had a similiar situation although the decision she had to make was more along the lines of who would be admitted to surgery first (only one functioning operating room). In the end she decided to go with the GSW. Her decision was based solely on the fact that it was a gunshot vs stabbing and a GSW is generally considered higher priority then a stabbing. (she is not entirely sure her decision was the correct one)

I understand her line of thinking but i can't help but think that a penetrating chest wound may pose more of a risk then a low calibre bullet into the abdo. Yes there is the possibility of substantial blood loss and the fact that there is no exit wound makes me wonder what the bullet ricochet off and what else may potentially be damaged.

[Richard B the EMT]

I understand her line of thinking but i can't help but think that a penetrating chest wound may pose more of a risk then a low calibre bullet into the abdo. Yes there is the possibility of substantial blood loss and the fact that there is no exit wound makes me wonder what the bullet ricochet off and what else may potentially be damaged.

First off, welcome to our world, where craziness is the norm.

In addition to internal bleeding from the GSW, there is the issue of dynamics from the bullet impact. With that in mind, the policies of NY State DoH, and the FDNY EMS Command, have the patient being long back board immobilized, in addition to trying to stop the bleeding. That may have been one of the concerns addressed by your intern friend, in making the decision to do the surgery on the GSW prior to the stab wound injury.

As to which patient should be transported first, local protocols, personnel training, and experience, will be involved in the decision.

Just as a mention: due to the dynamics of receiving a GSW, the body part will be kicked kind of hard. Soft Body Armor, the so-called "Bullet-Proof" vest (I say so called, because with the right ammunition, it will be penetrated, like a 22 caliber through my EMS design T-Shirts) spreads the impact area to absorb the shock, hence the lack of body penetration. LEOs (Law Enforcement Officers) who have been shot in the armor have described it as like being hit with a 20 pound sledgehammer.

Edited September 2, 2010 by Richard B the EMT