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<< Ballistic Injuries In The Emergency Department (Trauma CME)

Prehospital Care

Prehospital management of gunshot wounds varies somewhat based on the location of the injury, but almost all ballistic injury patients require immediate transport to a trauma center. Two large retrospective Canadian studies have suggested that direct transport to a Level I trauma center instead of a closer, non-trauma center results in better outcomes.23,24 Emergency medical services (EMS) providers should follow common ATLS® prehospital guidelines to control the airway, provide oxygen as needed, and control bleeding with direct pressure as well as obtain vital signs and intravenous (IV) access as soon as possible. Although EMS protocols will vary from region to region and each crew has varying capabilities, the EMS crew should perform lifesaving procedures as indicated but should primarily do their best to minimize transport time to the nearest trauma center.

Many patients with penetrating brain injury will have a depressed mental status and difficulty maintaining an open airway. The EMS providers may be authorized to provide advanced airway care in these patients, but recent literature suggests that out-of-hospital intubation in traumatic brain injury (TBI) may be associated with worse outcomes.25 Transport times and the proficiency of EMS with intubation will play a role in the decision to establish a prehospital airway. The wide array of supraglottic devices available offer easy-to-use and viable alternatives to prehospital intubation.

Because gunshot wounds to the chest can be immediately life-threatening, EMS providers must be able to rapidly treat and transport these patients to the nearest center capable of managing thoracic ballistic trauma with minimal on-scene time. Emergent life-saving interventions such as intubation and needle decompression should be the only procedures performed that may delay transport.26

Abdominal gunshot wound patients should be evaluated for hemodynamic stability, as they are at risk for life-threatening bleeding and many other injuries. If there is concern for a pelvic bleeding injury, pelvic compression may provide some prehospital stabilization of bleeding, but this should not delay prompt transportation.

Extremity gunshot wounds should be assessed for arterial bleeding and ischemia, specifically. If bleeding is found, attempt hemostasis by either direct pressure or use of a tourniquet. Prehospital tourniquet use had been discouraged for some time because the prevailing logic was that the constriction applied to control bleeding also led to occlusion of collateral flow, thereby worsening distal ischemia. However, recent evidence stemming from the conflicts in Afghanistan and Iraq supports the contrary: tourniquet use may prevent exsanguination and promote hemodynamic stabilization. A recent study by Kragh et al found that prehospital tourniquet use, when shock was not present, was strongly associated with survival compared to patients who did not receive them.27

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Last Modified: 07/19/2018
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