Quick and Dirty Guide to Penetrating Trauma Management
Note: This is intended as a starting point for a collaborative layperson's guide to handling a shooting / stabbing victim. I encourage others with a background in Fire/EMS and emergency medicine to contribute suggestions for additions or changes. Hopefully, we can get to a collaborative guide that can go in the how-to section.
Initial management of penetrating trauma.
(the Holiday Inn Express version)
Disclaimer: This is not intended as a substitute for formal first aid training by qualified instructors following an established curriculum. It is not intended as a replacement for the advice of a qualified physician. The reader assumes all responsibility, liability and karma repercussions for the use, misuse, abuse or non-use of any material provided herein. By reading this far, you agree in perpetuity to be bound by this disclaimer on behalf of yourself and your heirs, successors, pets and everyone you have ever met or will ever meet in this life or any past or future lives.
Caution: providing emergency care can expose you to all manner of nasty things including but not limited to HIV, Hepatitis, Tuberculosis and cooties. You can reduce (but not eliminate) your chances of exposure by wearing protective gloves and eye protection, exercising care around sharp items which may have been exposed to body fluids and good handwashing following providing care. Back in the old days of EMS, we used to come back to the firehouse covered in blood / brains / etc - it was the mark of a "good call". We were stupid back then. If you are exposed to someone else's blood or bodily fluids - particularly in your eyes, mouth or on broken skin, you should consult your personal physician for advice.
Penetrating trauma is any injury that occurs when an object penetrates the skin and enters the body. Depending on the location, depth and force of the event, penetrating trauma can disrupt the respiratory (lungs and air passages), cardiovascular (heart and blood vessels), neurological (brain and spinal cord), skeletal (bones and connective tissue) and / or musculature systems of the body. What follows is a basic guide to handling the first few minutes of post-injury care while waiting for EMS.
There is a "golden rule" in medicine - First, do no harm. However, on the street this "golden rule" comes AFTER the professional rescuer's prime directive - scene safety. It does absolutely no good to get yourself hurt trying to help someone else. You just end up compounding the original problem.
From an armed citizen's perspective, this essentially means that you need to have a scene where it is acceptable to go to Condition Yellow (a very pale yellow bordering on White), because the reality is that once you become directly involved in patient care, your ability to scan for danger will be greatly diminished. Tunnel vision isn't just for shooting.
Once you have decided to engage in patient care, we need to do a quick survey and see what we are dealing with. The first assessment point is Level of Consciousness. Is the victim awake? Are they responsive at all?
Level of Consciousness can be graded a number of ways. For the purposes of this guide, we'll use the AVPU system. In the AVPU system, there are 4 levels of consciousness:
- Alert (is looking around by himself and is aware of his surroundings)
- Verbal (isn't looking around, but responds to verbal stimulation. Responds when you say "hey, are you OK?")
- Painful (responds to painful / noxious stimuli like a pinch - this is not a license to abuse the victim! Save that for the guy who passes out at your next party)
- Unresponsive (doesn't do anything)
Level of Consciousness is a good indicator of how well - or how badly - things are going for the victim. An Alert patient, or one who responds to Verbal stimulation, is doing reasonably well. The lungs are bringing in oxygen, and the heart is able to move enough blood to get that oxygen to the brain.
The victim who responds to painful stimuli or does not respond at all is in trouble. Some combination of physical damage, insufficient air exchange or insufficient bloodflow has left the brain in a poor state.
Note - this would be an excellent time to call 911. You have the basic information the dispatcher will need to allocate the appropriate combination of assets (basic or advanced life support units, firetrucks carrying Paramedic Helpers, cops, helicopters, priests) to your patent. You'll also be much less lonely after a while if you call 911. (If you have to send someone to call for help, ask them to call for help AND COME BACK so you know the call was made).
If you have been trained in CPR, you are familiar with the ABCs (airway, breathing and circulation). It is beyond the scope of this thread to teach CPR. Everyone should know it anyway, so go take a class. (The sad truth is you are more likely to need CPR to save a loved one than your CCW. Get trained, ******.)
With the ABC's out of the way (either through training, or skipping over them because of lack of training), we now need to deal with the injury itself.
Important - if the injury involves an object that is sticking out of the body (knife, arrow, stick, etc) DO NOT REMOVE OR ATTEMPT TO REMOVE THE OBJECT. DON'T LET ANY "HELPFUL" BYSTANDERS DO IT, EITHER. If the object has damaged or severed a moderate or larger blood vessel, it may be applying pressure and slowing the internal bleeding. Removing the object may have a similar effect to removing a cork from a bottle....
Remember when we talked of First, Do No Harm? This is the time to put that into operation. Sometimes, the best thing you can do is talk to the victim, reassure them that help is on the way, and keep your mitts out of the problem.
Controlling bleeding is done via the use of direct pressure, elevation (when possible), and pressure points. (Some of you will notice that I have left off the "t-word", and you're right, I have left it off.)
In addition, there are some special things we may need to worry about with penetrating trauma to the chest or belly. We'll get to those in a minute.
Direct pressure is best applied with a bandage of some sort - preferably a sterile dressing manufactured for the purpose. If you must improvise, try to keep it clean.
Once you have applied a dressing to the wound, that first layer is never removed. If the bleeding continues through the dressing, add more material on top of it and keep the pressure on. (if you remove the first layer, you'll remove any clotting that might have begun and be back to square one).
If the injury is on an arm or leg - and that arm or leg is otherwise intact - you can lift the arm or leg up so the wound is higher than the level of the heart to help control the bleeding. If there is any doubt about the arm or leg being broken, leave it where it is and apply pressure.
Pressure points are locations on the body where the major arteries are close to the surface and running over bony structures - convenient shut-off valves for bleeding. I am only going to talk about 2 - one for the arm and one for the leg. For the arm, we use the Brachial Artery, located in the upper arm along the inside, sort of under the bicep. For the leg, the Femoral artery, which runs along the sides of the groin.
Of course, it is useless to close off the artery below the injury. So this only applies where the injury is found farther away from the torso that the pressure point.
The Brachial artery can be located on the inside of the upper arm, just below the bicep. Take the fingers of your left hand, and place them on the inside of your right upper arm. You should feel a sort of groove under your bicep. If you press gently on this groove, you should feel a pulse. If you press really hard, you'll occlude the artery and slow any bleeding from a wound farther down the arm. This is uncomfortable, so don't blame me if you get sore trying to make your hand go to sleep playing with this pressure point.
The Femoral artery runs along both sides of the groin in the groove between leg and crotch. If you gently press along this groove, you'll feel a rather large pulsating blood vessel. Using the heel of your hand, apply firm pressure over the pulse to slow bleeding from a wound further down the leg.
As one might expect, you do need to apply pressure to the pressure point on the injured side.....
So what about the head, torso and pelvis? Well, there really aren't pressure points there that we are going to get into. There are pressure points for the scalp, but before you go clamping down on them you need the assessment skills to check for underlying injury. Pushing stuff into the brain falls into the category of not helpful.
Bleeding inside the torso, abdomen or pelvis requires bright lights and cold steel to fix - also known as an operating room. While you can stop surface bleeding with pressure, that's probably not going to shut down the internal leak. And yes, you can bleed to death internally. Any time delay between an injury causing internal bleeding and a close encounter with a surgeon is a Bad Thing. Aren't you glad you called 911 once you had evaluated the Level of Consciousness?
Just a couple more things to add here about the torso and abdomen - sucking chest wounds and evisceration.
Sucking chest wound. Kind of redundant to the layperson - after all, wouldn't having any wound in the chest suck? Of course it would, but that's not what the term means.
When you breathe out, your chest contracts, increasing the air pressure in your lungs and causing air to flow up the windpipe and out the mouth and nose.
When you breathe in, your chest expands. This lowers the pressure in your lungs and causes air from the outside to flow in through your mouth and nose and down the windpipe into the lungs. The air flows in through the mouth and down the windpipe because that is the only available route.
The lungs are kind of like foamy balloons, and normally they fill the chest cavity. There is a "potential space" between the lungs and the chest wall. It is a potential space because there is normally nothing in it except for a little bit of lubricating fluid.
But if we puncture the chest wall, air now has a way to enter the "potential space" between the lung and the chest wall. When the chest expands, air is sucked in through the hole in the chest wall - hence a sucking chest wound.
Sucking chest wounds suck in both the literal and figurative senses. As air enters the space between the lung and the chest wall, it leaves less space for the lung to expand. As more and more air becomes trapped in this space, the lung progressively collapses.
So as a part of our initial management of this poor unfortunate victim, we want to try and prevent air from getting into the chest cavity. So we will need to occlude any wound that has the potential for letting air in - even if we cannot see bubbles indicating that air is going in or out.
In the short term, the best tool you have available for this is a gloved hand (or an ungloved hand if necessary). Just place it over the hole and push down, creating an airtight seal.
Important note - depending on when in the cycle of breathing in and out the wound was inflicted, even a puncture as low on the torso as the belly button can be a sucking chest wound. Treat accordingly.
If you are presented with a large enough hole in the abdomen, the abdominal organs may well try and escape. If this happens, there are a couple things you need to know for your management of the victim while waiting for EMS.
First, do not try to put the exposed organs back where you think they belong. Yes, they are far more esthetically pleasing *inside* the abdomen, but that's a job for a surgeon.
Second, do not push on the exposed organs. Cover them with a bulky dressing and leave them alone. Make sure the first trained rescuer who arrives is told that there are guts exposed under the dressing (or T-shirt depending on how much first aid stuff you had available).
One last thing to remember - bullets often enter the body, do their thing and then leave. Don't get totally fixated on one hole and ignore the other. If either hole could have penetrated the chest cavity, you must occlude them both.
I'd strongly encourage anyone reading this to take a first aid and CPR course from your local fire station or Red Cross chapter. It's really just as important as any other defensive training you can acquire.