Penetrating Trauma and Gunshot Wounds

Penetrating Trauma

• Classified into low, medium, and high energy
• Low energy: accidental impalement or intentional by knife or ice pick
• High energy: gunshot wounds, resulting in more significant injuries

Gunshot Wounds

• Trajectory: path of the projectile
• Fragible bullets: increase damage due to multiple fragments
• Full Metal Jacket bullets: cause less damage due to minimal fragmentation
• Bullet speed: major factor in resulting injury pattern
• Cavitation: temporary cavity produced by stretching tissue surrounding the point of impact
• Permanent cavitation injury: results from pressure fluctuations closer to the bullet path

Blast Injuries

• Categories: primary, secondary, tertiary, and miscellaneous
• Primary blast injuries: entirely due to the blast itself, damage to compressible structures (lungs, eardrums)
• Secondary blast injuries: result from being struck by flying debris, blunt and penetrating injuries
• Tertiary blast injuries: result from being hurled by the force of the explosion, blunt and penetrating injuries
• Miscellaneous blast injuries: result from miscellaneous events during the explosion (heat, biologic/chemical/radioactive contaminants)

Blast Injury Effects

• Primary blast injuries: proximity to the origin of the pressure wave increases risk of injury or death
• Pulmonary blast injuries: result from short-range exposure, lack of external visible injuries, may report tightness or pain in the chest, coughing up blood
• Subcutaneous empyema: air in the thorax, feels like Rice Krispies under the skin
• Pneumothorax: common injury, may require emergency decompression
• Arterial air embolism: may recur rapidly

Prehospital Trauma Care

• Golden principles:
  • Ensure safety
  • Determine need for additional personnel or equipment
  • Identify and manage life threats
  • Assess and manage airway while maintaining c-spine
  • Ensure basic shock therapy is completed
  • Keep patient warm, oxygen administration is highly indicated
  • Rapidly proceed with spinal immobilization if indicated
  • Identify life-threatening injuries and illnesses as soon as possible

Trauma Patient Assessment

• Head injuries: disability and unseen injury to the brain may occur, bleeding or swelling inside the skull is often lifethreatening
• Neck and throat injuries: may result in airway problems, look for decapitation, swelling may prevent blood flow to the brain
• Chest injuries: fracture ribs or sternum, large vessels of the heart may be torn, pneumothorax, hemothorax
• Abdominal injuries: solid organs may tear, lacerate, or fracture, hollow organs may rupture, causing toxic fluids to leak
• Trauma lethal triad: hypothermia, coagulopathy, and acidosis

Trauma Patient Management

• Aggressively seek to control all bleeding, consider using a tourniquet
• Ensure IV fluids are warmed to at least normal body temperature
• Monitor entitle carbon dioxide and ventilations, consider calling for ALS backup
• Limit scene time to an absolute minimum, ideally less than 10 minutes

Transportation

• Ground or air transportation, consider factors such as:
  • Extrication time
  • Distance to a Trauma Center
  • Need for medical care and stabilization at the advanced life support level
  • Availability of ALS ground level ambulance
  • Traffic conditions, Hospital availability
  • Multiple patients overwhelming resources at the trauma center
• Transport to the most appropriate facility based on patient injuries, considering hospital resources available in the area

Penetrating Trauma

• Classified into low, medium, and high energy, with low energy including accidental impalement or intentional injuries by knife or ice pick, and high energy including gunshot wounds resulting in more significant injuries.

Gunshot Wounds

• Trajectory refers to the path of the projectile.
• Fragible bullets increase damage due to multiple fragments.
• Full Metal Jacket bullets cause less damage due to minimal fragmentation.
• Bullet speed is a major factor in resulting injury patterns.
• Cavitation produces a temporary cavity surrounding the point of impact.
• Permanent cavitation injury results from pressure fluctuations closer to the bullet path.

Blast Injuries

• Categories include primary, secondary, tertiary, and miscellaneous.
• Primary blast injuries are entirely due to the blast itself, damaging compressible structures like lungs and eardrums.
• Secondary blast injuries result from being struck by flying debris, causing blunt and penetrating injuries.
• Tertiary blast injuries result from being hurled by the force of the explosion, causing blunt and penetrating injuries.
• Miscellaneous blast injuries result from miscellaneous events during the explosion, such as heat, biologic/chemical/radioactive contaminants.

Blast Injury Effects

• Proximity to the origin of the pressure wave increases risk of injury or death.
• Pulmonary blast injuries result from short-range exposure, often with no external visible injuries, and may present with symptoms like tightness or pain in the chest, and coughing up blood.
• Subcutaneous emphysema is characterized by air in the thorax, feeling like Rice Krispies under the skin.
• Pneumothorax is a common injury that may require emergency decompression.
• Arterial air embolism may recur rapidly.

Prehospital Trauma Care

• Ensure safety and determine need for additional personnel or equipment.
• Identify and manage life threats, and assess and manage airway while maintaining c-spine.
• Ensure basic shock therapy is completed, and keep the patient warm, with oxygen administration highly indicated.
• Rapidly proceed with spinal immobilization if indicated.
• Identify life-threatening injuries and illnesses as soon as possible.

Trauma Patient Assessment

• Head injuries can result in disability and unseen brain injury, with bleeding or swelling inside the skull being often lifethreatening.
• Neck and throat injuries can result in airway problems, with decapitation and swelling potentially preventing blood flow to the brain.
• Chest injuries can cause fracture ribs or sternum, tear or rupture large vessels of the heart, and pneumothorax or hemothorax.
• Abdominal injuries can tear, lacerate, or fracture solid organs, or rupture hollow organs, causing toxic fluids to leak.
• Trauma lethal triad consists of hypothermia, coagulopathy, and acidosis.

Trauma Patient Management

• Aggressively seek to control all bleeding, considering using a tourniquet.
• Ensure IV fluids are warmed to at least normal body temperature.
• Monitor entitle carbon dioxide and ventilations, considering calling for ALS backup.
• Limit scene time to an absolute minimum, ideally less than 10 minutes.

Transportation

• Consider factors such as extrication time, distance to a Trauma Center, need for medical care and stabilization at the advanced life support level, availability of ALS ground level ambulance, traffic conditions, hospital availability, and multiple patients overwhelming resources at the trauma center.
• Transport to the most appropriate facility based on patient injuries, considering hospital resources available in the area.

Learn about penetrating trauma classified into low, medium, and high energy, and gunshot wounds including trajectory, bullet types, and cavitation.