Shot in the head. Did we do the right thing?

[fiznat]

We responded this past friday to a triple shooting. 3 kids in the ghetto all under 21.

Our patient was a 16 year old male found on the sidewalk shot in the head and chest. Two other crews were taking the two other patients, so there was no triage issue. Our patient was shot directly in the forehead with brain matter visible, his whole forehead caved in from the force of the impact. The patient was also shot in the left side of the chest pectoral region. No visible exit wounds for either bullet. The patient had a distinct carotid pulse, tachy, not breathing. OPA placed, BVM ventilations. Board + collar and he was in the rig. I get the monitor on while the medic goes for the tube, which he is unable to get cause of blood continuing to fill the airway despite constant suction. With every BVM compression, air is forced through holes we now notice throughout the top of the kid's skull. Lung sounds with BVM are amazingly equal, although junky - presumably from blood.

On the monitor the patient is in a wide complex tachycardia that we call VT. We still have pulses and my medic wants to cardiovert. We throw the pads on and hit him. Converted to PEA. The patient gets CPR and BVM enroute to the hospital. I drive. We are about 2 minutes away, my patch to the hospital is something along the lines of "Enroute to your facility ETA 2 minutes. Male patient young teens shot in the head and chest. Traumatic arrest. Was VT with a pulse, now PEA. Working on the ALS, we'll see you in 2 minutes." No time to get a tube or line enroute. On-scene time was 6 minutes, we are at the hospital within 2 minutes.

We roll him into the trauma bay and the heads are already shaking no. The kid is obviously dead, but they work him for a few minutes anyways. They get a tube and call him.

My medic confided in me that he wonders if he did the right thing. Specifically about the cardioversion. I told him yes, he did everything he could have possibly done and we did a great job - bieng as quick as we were. Still though, I'm not so sure. I mean, obvioulsy the point is mute with the type of injuries this kid had, but it is an interesting point nonetheless: did this trauma patient need cardioversion?

We we taught in medic class that unstable VT needs cardioversion as it is an unstable rhythm. Still, this is trauma on a patient we expect to code any second. He is shot through the chest and once more in the head. I was happy we had pulses at all. If the situation were different, if he was in VF or something first and we shocked him, converting into VT with a pulse, we probably would have been happy to have that rhythm, right? I cant imagine that we would consider cardioversion at that point. This patient had a million things going on, with blood in the thorax, a bullet in the brain, and no airway. What do you guys think: should we have just been happy to have pulses, or did we do the right thing?

[evjm]

I'd say you did the right thing by cardioverting. I'm sure if you had brought him into ER with VTach and a pulse they would have cardioverted him, why delay it? The BP probably wasn't the best with the VTach anyway.

[ncmedic309]

It sounds like your response was too quick! It sounds like you managed the situation just fine, he still had signs of life in the field and you guys attempted to get him to the ED alive. We know before hand that our efforts are not going to make a difference, this kids dead and there's nothing anybody can do to change that. You have a shockable rhythm, regardless if it's medical or traumatic etiology, you still treat it the same. I know some departments are going away from doing ACLS on traumatic arrests, mainly because it doesn't make a difference.

So here's another question, if your not going to throw ACLS drugs at the patient, would you opt out of electrical treatment as well?

[paramedicmike]

Wow! Tough call. That really sucks. Sorry you had to deal with that.

I don't know that I would've made the same decision to cardiovert this kid. What you saw on the monitor could've been from a variety of things with hypoxia being high on that list.

You said his airway was full of fluid. I've seen these airways. They absolutely, positively suck. But I think Id have spent the effort on airway first. If, in the off chance, you get a tube placed, correcting the hypoxia could correct some of the other things you're seeing.

Did you manage to get a BP with the pulse? I'm not a huge fan of the NIBP cuffs but in a case like this they can be a good thing. With palpable pulses and a BP combined with your amazingly short on scene and mercifully short transport times I would have not gone the same way.

I'll add the disclaimer that I, obviously, wasn't there. It's fine and easy for me to type this from the comfort of my kitchen table. So please keep that in mind as you read this.

Good on you for trying to take care of your partner. Good on your partner for trying to figure out a better way to handle things for the next time you find yourself in a similar position. Perhaps convince him to follow up with your medical director or an ER doc you know and trust to talk about how the call went? That might be beneficial to you guys, too.

Tough call. If you need us for anything else just let us know.

-be safe

[vs-eh?]

No cardioversion.

Penetrating trauma is a surgical problem. ABC - intubate, chest needle (if needed), IV and go to the hospital if you have a pulse.

Strong decision for a pronouncement or a least a patch for direction if no pulses.

Agree with paramedicmike - concentrate more on establishing a secure a/w, and a BP when you had a pulse would have been warranted.

Live and learn.

[fiznat]

Live and learn.

No doubt about that, man.

Thanks for the comments guys. To answer a few questions, no we never got the oppertunity to get a blood pressure. The medic got 1 missed attempt at the airway while the monitor was going on, and once it was on and he saw the rhythm, then decided to cardiovert. I realise it is out of order for ABC... but we already attempted the ETT once by that point. Also, OPA + BVM was getting effective vents based on our lung sounds.

I was going to hook up the NIBP but after we shocked there was significantly less need for it, heh...

The crux of the question really is whether this patient needed cardioversion or not. Assume an ETT was already placed, a line in and running, and all the BLS is done. Would you cardiovert then? The question really is: in a patient who has a pulse but by all rights shouldnt, should we go in and start messing with rhythm issues? I'd be happy just to have a pulse, and at the carotid we know we have at least 70 systolic which is enough for CPP assuming no increased ICP. (this patient obviously had some significant ICP changes but still) Isnt that pretty damn good, considering we expected him to be pulseless?

[AZCEP]

Some of this kid's organs may have fewer issues than his brain and lungs do. Keeping him alive to justify harvest might be the best thing this particular patient does for society.

[Asysin2leads]

I'm not going to say that cardioverting him was necessairly the wrong thing, but I agree with the others that in traumatic situation in a young, previously healthy individual with no signs of blunt force chest trauma, the VT is probably caused by myocardial irrability secondary to hypoxia and acidosis, and so establishing an airway and reversing the hypoxia and acidosis is what's needed to correct the situation. If any of the council of elders wants to weigh in on the issue of trauma induced v-fib/v-tach, I'd love to hear it, but that's my understanding. On the other hand, no one is going to fault you for cardioverting v-tach. Our protocols to not differentiate between medical and or traumatic v-fib/pulseless v-tach, so defibrillate and be merry. The long and the short of it is that you got to a trauma victim and got him to the proper facility in an amazingly short amount of time and were even able to pull off some interventions in route. You really can't ask for any more than that. Good job.

[Wraith]

What a messed up situation. I truly feel for you guys. Right place at the wrong time. Does your organization utilize combitubes? Have found them to be wonderful in situations like this. As for the Wide complex tach, it could have been caused by any number or combination of things ranging from hypoxia to severe head injury to traumatic injury to the cardiac muscle itself. The point remains the same though. There wasn't much that could have improved this kids chances for recovery. Don't beat yourself up too bad.

[alpha23958]

With what sounds like a nasty TBI, I'd his injuries were not compatible with self-sustaining or prolonged life. Cardioversion may not have hurt in this case, what's on the monitor doesn't tell all. Were the complexes comparable to a pulse, I mean were they profusing or non, something like PEA?

If you find him DOA, let it be; but if there is a chance at getting him to an ER, viable or not, at least they have the chance for organ donation.