Gunshot Wound Trauma Care

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As I am employed as a Police Officer I occasionally get to do something other than eat donuts, and violate people’s constitutional rights.  So when my boss told me to sign up for Strategos International’s Tactical Medical Responder course, I jumped at the chance as I knew the quality of their instruction previously attending their Law Enforcement Response to the Active Shooter Instructor class.  I am not an EMT or Paramedic and before this class my knowledge of treating gunshot wounds or trauma was little at best.  This training was based off of the US Military’s Tactical Combat Casualty Care program or TC³.

So why am I talking about this if this blog is dedicated more towards competitive shooting? Because we shoot guns, and there is always a chance of someone shooting themselves or another on accident (or on purpose).  Do you know what to do?  Do you have any equipment to treat them, do you trust that the range staff or someone else has it?  What is the response time for an ambulance to arrive at a range out in the boonies?  This is a basic write up of what we would be able to do at the range with minimal supplies and minimal training, to hopefully save the life of a person.

The normal adult blood volume for a person is about 5 liters.  If a major artery is cut a human being can lose 1 liter of blood in 30 seconds.  At about 1.5 liters the person starts to become anxious and their radial pulse starts to weaken and respiration starts to increase.  At 2 liters they start to become confused, heart rate increases even more to make up for the loss of blood pressure.  2.5 liters of blood lost will cause the person to be unconscious, and their radial pulse would be absent.  Without immediate medical care and blood replacement, the person is likely to die.

Thus if someone is shot, the first thing to do is to stop or limit the massive bleeding.  Then take care of the airway and ensure they can continue to get air to their lungs through their mouth or nose.  Next is taking care of respiration, the chest cavity of a human is under negative pressure and if you poke a hole in it the lungs can collapse and shift, so sealing the hole is important.  If you get air in your chest cavity outside of the lungs, it is called a pneumothorax.  Then take care of any other bleeding, and check for head injuries and ensure no hypothermia from conduction to whatever surface they are laying or sitting on.

Tourniquets:

In general if it is life-threatening bleeding or suspected from an extremity.  Traditional instruction says it is best to place the tourniquet at least 2 inches above the critical bleeding site, but stay at least a hands width from elbows or knees to prevent crushing of the nerves which was the true cause of the loss of limbs from tourniquets.  It is easiest to remember to put it on high and tight, crank it down until the blood stops pouring or squirting out.  Don’t take it off and don’t let the patient take it off, and it will be painful.

The purpose of the tourniquet is to prevent blood loss and promote clotting.  Do not relax the tourniquet on occasion like it used to be taught, this will just blow out whatever clotting had occurred and make it more difficult for clotting to occur later.  Once it has been placed, it should be reassessed for conversion to a hemostatic agent or pressure dressing within 2 hours according to the TC³ committee.  But as soon as they get to the ER they will do what they need to do.  While all the tourniquets have a place to write the time applied on them, just use a black marker that should also be in your kit and write TR and the time applied on their forehead.

What tourniquet to use?

Military studies show that only two of the tourniquets on the market for the “tactical” crowd are truly effective, they are the C-A-T tourniquet and the SOF tourniquet (SOF-T), both windlass style.  Watch out for knockoffs created for the airsoft market, in the case of the C-A-T all reports of breakage from the sandbox it turned out they were the knockoffs.  I have both the C-A-T and the SOF-T and I prefer the C-A-T.  I find it easier for one-handed application on yourself, it is easier to cinch tight and then crank it tight with the windlass.  The SOF-T is a bit easier to apply on another person’s leg as they have a quick release to allow you to quickly wrap it around, then cinch down, but is very difficult to cinch it down on yourself one handed.  Both are fine tourniquets and as long as you train with them, both will be effective.  They are designed for one time use, so buy two, one to use in an emergency and one for practice.

Compression Dressings:

There are many types of compression dressings, I have trained with most brands and designs and my favorite is the OLAES Modular bandage.  They come in 4″ or 6″ widths and have about 3 foot of gauze packed in them if you need it, along with a transparent plastic occlusive sheet that can be used as a chest seal if needed.  The bandage has a little plastic cup that allows you to place the dressing pad over the wound, and when you wrap it the plastic cup presses into the wound to apply direct pressure.  There are also velcro stop strips along the length of the elastic wrap, ensuring that the wrap will not just come unravelled and hit the dirt.  Although even if it does just shake it off and apply it, they will be at a hospital on broad spectrum anti-biotics soon enough.

While a compression dressing can give a tourniquet like effect they will not substitute for a true tourniquet.  Apply the tourniquet first then cover up the wound with a compression bandage.

Hemostatic Impregnated Gauze and Hemostatic Agents:

This a gauze impregnated with a material to stop blood flow, and as the gauze is pliable you can pack it into any size or shape of wound including penetrating wounds such as gunshots or knife wounds.  Examine the wound and determine the point of bleeding.  Pack the gauze directly over the point of contact, and ensure that the gauze is directly contacting the point of bleeding.  If there is a large wound with a lot of pooled blood, wipe and remove as much of the pooled blood as possible before packing with the hemostatic gauze.  Pack the wound entirely and if you have any extra ball it up and use at the top of the wound to help apply pressure.  Apply 3 minutes of direct pressure. Do not lift the dressing to reassess the bleeding or the wound.  If the dressing soaks through entirely or there is still active bleeding at the base of the dressing after 3 minutes, remove and apply a new one.  If no active bleeding after 3 minutes of direct pressure, apply a compression bandage or elastic bandage over the dressing.

The new formula of powdered QuikClot doesn’t cause the burn wounds that the old formula used to and if you have the old powder version of QuikClot dispose of it.  Celox Powder is still good to go.  The problem with the powder and a topical application, the powder may never reach the actual bleed point.  So you would have to pour it into the wound and then pack the wound with gauze.  Why not just buy the impregnated gauze?  Both QuikClot and Celox have a Combat Gauze and both are good stuff.

Airway:

Once you have the bleeding controlled then make sure that they can still breath on their own. The most common obstruction of the adult airway is the tongue.  Put them in a comfortable position so they can breath easily.  If they are in danger of losing consciousness, place them on their side in the recovery position or place a Nasopharyngeal Airway (NPA) in and they will be able to breath even if they pass out as it will keep the airway open.  They do make different size NPA’s but the most common for adults is a 28 French size.  It is a simple pliable PVC tube, that you lubricate the NPA and then insert it into the nose.  Youtube video of insertion, it looks worst than it is and it is actually pretty simple. If you don’t have lube, use their spit, your spit or their fresh blood (don’t use clotted).

Chest Seals:

Use a chest seal when there is any penetrating wound or puncture to the chest where air exchange through that wound is observed or suspected.  Simplest thing to do is buy a commercial valved chest seal, the commercial seals are great as they are sticky enough to stay on through sweat, blood and chest hair.  If a valved chest seal is not available then you can improvise with any material that will not allow water or air to pass through.  Placing a cover over the hole usually brings relief to a person with a pneumothorax.  If the seal is not vented then you may have to “burp” it, by lifting the seal and allowing air to escape.  If there is one hole, look for another especially with a gun shot wound, so make sure to seal both holes.  I prefer the SAM Chest Seal with vent, or the HyFin with vent.  In a pinch even placing duct tape over the holes will seal the holes.  Just monitor the person and burp the seal when needed.

Hypothermia:

While waiting for EMS, keep the person comfortable, but be aware that hypothermia can be a problem.  A person can become hypothermic at almost any temperature, especially if they are sitting on or laying on the ground.  Don’t just throw a blanket on top of them, as they will still lose body heat through conduction with the ground.  Place them on a blanket or something else, then another blanket on top.  Emergency blankets work great for this, and pack small.

Shock:

Shock is ultimately what causes everyone to die.  Shock is inadequate tissue perfusion, or not enough oxygenated blood being circulated to all body tissues.  It is a physiological protection response that initially occurs to address an injury.  It is not a state that your body lapses into because of an injury as most people think.

Stay with the person, and use positive reassurance, treat them confidentially, maintain your own self control.  Maintain the person’s airway with comfortable breathing.  Treat the injuries and make them as comfortable as possible and elevate the legs.

The full kit:

Tourniquet, I prefer more than one.
Compression bandages, x2
Combat Gauze, x2
NPA with lube
Tape
Shears
Emergency blankets

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