You are called to a 35-year-old male who has been shot once with a shotgun. The patient has no medical history to report.
Police are on scene and have detained the alleged perpetrator. They confirm that one male has been shot in a random attack and the scene is now safe. The patient is in the back of an ambulance and the crew have attached monitoring and administered 15 litres oxygen through a non-rebreathe mask.
RR - 28
SpO2 - 98% (15 litres O2)
HR - 122 regular
BP - 129/108
CRT - 4 secs
Tº - 35.6
PEARLA @ 5
What is your next move?
Although it is difficult to tell at first glance, gaining a history from the patient’s friend reveals he was shot from directly in front and an assessment of his back reveals no further injury. The patient has multiple penetrating intra-abdominal pellets (several of which are later found to be in the small bowel and colon) causing active, vascular haemorrhage but no arterial haemorrhage. It is at night and the incident occurred on grass so it is impossible to accurately assess ‘blood on the floor…’ (1, 2).
Clear, present, and self-maintained, there is no injury to airway.
The patient was shot and collapsed on to soft ground, as such the MOI does not require C-spine immobilisation. A great blog piece by 'KI Docs' summarises a modern approach to C-spine management and highlights the detrimental effects of 'just in case' immobilisation (3).
RR may initially be raised due to anxiety, however a physiological tachypnoea takes over during the course of his treatment in response to haemorrhagic shock. Chest rise is good and air entry is normal bi-laterally.
The patient is tachycardic due to the haemorrhagic shock. The patient is later found to have two pellets in the inferior right ventricular wall of his heart, however there was no bleeding into the pericardial space.
Initially the intra-abdominal bleeding causes a dynamically narrowing pulse pressure, which is followed by a drop in blood pressure to 80/55 during the course of his treatment (4, 5). The patient has multiple penetrating injuries to the abdomen and chest but no injuries to his head or extremities. Although there is minimal evidence in humans regarding the ideal fluid management in haemorrhagic shock, guidelines suggest fluid management should achieve verbal contact (to indicate cerebral perfusion) unless the patient is unconscious, in which case systolic blood pressure should targeted at 80 mmHg or 60 mmHg for peripheral or central penetrating trauma, respectively (6, 7). This strategy, combined with TXA administration (8) achieves physiological haemostasis before arrival at the ED.
The patient is alert and orientated, he is anxious and still in ‘fight or flight’ mode, resulting in pupillary dilation and physiological compensation for his underlying injuries. He is GCS 15 throughout treatment, is orientated to time and place, has full recollection of the incident, and is compliant with medical intervention.
It is the middle of January at 23:00. The patient’s core temperature was taken on arrival when the patient was wearing a jacket and trousers, he has since been stripped ‘skin to scoop’ by the crew and the ambulance heater has not been turned on. As a result his temperature is dropping. Using blankets and turning on the ambulance heater ensures a good core temperature and minimises coagulopathy (9).
When questioned, the patient denies any alcohol or drug consumption.
This fictional case study was based on a video by Larry Mellick at the Medical College of Georgia.