GSW vs Pentrating chest wound

[FozMedic]

Hi All,

There seems to be a focus on a tension pneumothorax in the case of the stabbing victim. If I am reading the scenario right, there is equal air entry and chest movement bilaterally. If the JVD was a result of a tension, there would be minimal if any chest movement or breath sounds on the left side, as JVD is a late indicator of this condition. I agree with CHBare that one would have to assume Tamponade is the cause of the JVD, which would lead me to make that patient the priority. This is not to say the GSW is not serious and would also require rapid intervention and transport, but being that I could only take one patient, the SW would be my first choice.

Thanks for reading,

Foz

Edited September 4, 2010 by FozMedic

[Lone Star]

From what I read, it's not a matter of 'who gets transported first', but a matter of 'who gets ALS treatment, and who gets BLS treatment.

Since pulse ox and cardiac monitors are not working (shouldn't that have been corrected at the begining of the shift, BEFORE you put 'in service'?), I would treat the stabbing victim as a potential hemothorax and cover the stab site with an occlusive dressing (if the weapon has already been removed) and tape it down on 3 sides. IV (NS/KVO)and pass him off to BLS. If the weapon is still in place, secure it with a 'donut dressing' and transport it as is.

The GSW is concerning me more. Low calibre (I'm presuming .22, .25, .32) with no exit wound. Since I'm not formally in a medic class, my treatment options are still in that 'grey area' due to I haven't learned them yet. The bullet could have gone anywhere in the body after the initial penetration, so even in the best case scenario, we're talking about multiple system involvement.

I would also be trying to figure out which pain med I could administer so that the patients are as comfortable as possible, without compromising respiratory function.

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.

Herbie, if you remember, a penetrating abdominal injury is an automatic contraindication for MAST. Isn't a GSW to the abdo considered a 'penetrating abdominal injury'?

[HERBIE1]

Herbie, if you remember, a penetrating abdominal injury is an automatic contraindication for MAST. Isn't a GSW to the abdo considered a 'penetrating abdominal injury'?

I admit it has probably been at least 15 years since I have used the MAST suit on a patient- we no longer even carry them. I do recall that in our system, penetrating abdominal injury was a RELATIVE contrainidication for MAST, meaning we could apply them, inflate all but the abdominal compartment (needed a DR's orders), but impaled objects and eviscerations were absolute contraindications. Pregnancy meant that with an MD's orders, you could also apply the suit and only inflate the legs.

Below is the part of the scenario that I was initially stuck on, and made a couple assumptions based on my interpretation of the situation. This simple phrase to me meant that there were 2 BLS rigs, and I would be able to jump on board with only one of the 2 patients to provide ALS care, so this was essentially about triaging. I may have misinterpreted these parameters, and if so, mea culpa.

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.

I assumed that this meant there were 2 BLS rigs, and you- as the ALS provider- would be only able to provide ALS care to one of the patients, while the other would be transported BLS. I was trying to come up with BLS interventions and prioritizing the patients based on what I could do for them. As I mentioned, as an ALS provider, there would be little prehospitally I could do for the GSW to the abdomen. If the patient with the potential for a tamponade or pneumo crashed, I could provide help for that person beyond the scope of an EMTB . I was thinking in desperation mode- try everything you can based on a difficult situation- which is really what much of our jobs often entails. Obviously, transport times also play a key role in the decision making process for triaging, treatment, and transport.

Brings back memories- some horrible, like power washing the remnants of a GI bleed or bloody trauma from the suit. When I first started in EMS, MAST pants were part of the protocol on nearly every cardiac arrest- traumatic or medical. We became quite proficient at quickly applying them- and even learned that by putting your arms through the suit's legs(which were already closed by the velcro) and grabbing the patients legs, we could simply slip them on the patient and all that was left was to apply the abdominal portion and inflate. The hardest part of the process became getting the suit out of the case- and keeping the ER staff from cutting them when they arrived at the ED, of course. LOL

Like the studies now indicate, their value for autotransfusion may have been neglible, but I found they were quite effective for splinting things like pelvic fractures. The patient was more comfortable, it made patient movement easier, and the often bumpy transport was much more comfortable for them.

Who knows-maybe MAST will someday make a come back since things in EMS old is sometimes new again: Think sodium bicarb.

I sincerely hope that rotating tourniquets have gone the way of the dinosaur, however.

Thanks for keeping an old fart like me on my toes, Lone Star.

[CBEMT]

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.

Oye. They really need to read the Maryland study.

Herbie, if you remember, a penetrating abdominal injury is an automatic contraindication for MAST. Isn't a GSW to the abdo considered a 'penetrating abdominal injury'?

Here penetrating abdominal trauma is considered one of the primary reasons FOR considering MAST. In fact its the most common scenario used at final practical testing. Penetrating chest trauma is an automatic no-go, however.