Penetrative Trauma - Case Study Example

Case Study Student’s Name Institution Case Study Introduction It is 0730 hours on a coldish spring morning. I am dispatched to a report of a man in a boarding house (supported accommodation) known for frequent disturbances who is unconscious. Upon arrival, I find an approximately 45-year-old male with multiple stab wounds to the chest, back and arms who is lying prone in a pool of blood outside wearing blood-soaked singlet and underpants. I note on primary assessment that he is drowsy, confused, pale and cool to the touch. On further assessment I find the following scenes: No danger - victim states person who stabbed him (unknown) has left the scene and no weapon near the patient. The patient responds to voice (confused). Respiratory rate = 32 (shallow) - equal air entry with no adventitious sounds on auscultation, trachea mid line, increased effort and SpO2 = 92%, Pulse = 132 regular, weak, thready, Skin = cool, pale, diaphoretic, ECG = Sinus tachycardia, BP = 70/45, Central capillary refill = 4 seconds. Patient eye opening to voice, confused verbal response and obeying motor commands, BGL = 4.2mmol/L, pupils equal and reacting to light, tympanic temperature = 35.5 degrees Celsius, no drug paraphernalia present, pain = 4/10, patient weight = 67kg (estimate). Exposure of patient shows 20 stab wounds (lacerations approximately 3-5cm deep and lengths varying from 5cm-10cm) to the chest, back and arms with estimated time of injury 2300 hours night before (8.5 hours ago). No other injuries found. Patient has a history of alcohol abuse (been sober for one month), currently taking no medication and is not allergic to anything. Management and Preliminary Diagnosis After arriving at the scene, I will ensure that I park my car in a manner that would facilitate an effortless departure from the scene. Then I will begin investigating the patient. I will check the injury’s cause, the number of the patients and whichever possible hazards. I will also find out whether extra resources would be demanded such as police or EMS units. I will then determine the approximate age of the patient, injury or bleeding even ahead of touching or talking to him. I will kneel near him in a manner that will not cause him to move his head fast and look at me. I will take precautions of spinal immobilisations immediately since the penetrating injury might have caused injury to the spinal cord or cervical column. Then, I will examine the airway of the patient. If the patient does not have a patent airway, I will open it with jaw-thrust manoeuvre with the purpose of minimising further harm. I will suction the patient if the airway is filled with blood. If the patient is not breathing, I will offer two breaths and test a carotid pulse. I will then determine the breathing rate. While assessing the breathing rate, I will check and palpate the chest for life-menacing injuries such as flail chest or chest wound. I will put an occlusive dressing over every infiltration to the chest in the case of the sucking chest wound. The revelation of flailed chest will demand the wounds being supported by a massive dressing. Afterwards, I will check massive loss of blood together with other connected hemorrhagic shock signs. After locating the bleeding’s origin, I will bandage the penetration’s site. If bandaging does not control bleeding sufficiently, I will put manual pressure upon the penetration’s site as well as the local point of pressure. I will also examine the bilateral radial pulses. After making the mentioned observations, I will immediately call an ambulance for taking the patient to the nearest trauma centre. I will use CT scanning and X-ray in identifying the location and potentially dangerous injuries. I will also give intravenous fluids to the patient for replacing the lost blood. The preliminary diagnosis for the patient in this case study is that he is suffering from penetrating trauma. Penetrative trauma is an injury (or injuries) which occur the moment the skin is pierced by an object thus, entering the body and creating an open sore (Giffard, 2011).The piercing object might stay in the tissues, return as it entered, penetrate through the tissues and move out in another locality. Fragments of broken bones or foreign objects are the common causes of penetrating trauma. The causes of penetrating injuries are stabbings and gunshots. Nonballistic weapons or objects such as ice picks or knives used from near distances cause low-energy wounds (Giffard, 2011). Penetrating trauma is dangerous as it sometimes damages internal organs and poses risks infection and shocks. The injury’s severity varies broadly depending upon the involved body parts, the penetrating object’s characteristics, and the energy amounts passing on the tissues. Pathophysiological Process of Penetrating Trauma Penetrating injuries are capable of causing damages to the heart, diaphragm, chest wall, great vessels, oesophagus, and tracheobronchial structures. The most regularly affected ventricles are the right ventricles due to their large size and closeness to the anterior thoracic wall in relation to the left ventricle (Scharff, & Naunheim, 2007). Often, those injuries cause an instant pericardial tamponade which decreases cardiac output, bringing about shock. Likewise, the chest’s great vessels injuries (particularly, the pulmonary vessels, superior vena cava and aorta) are as well common with the penetrating chest trauma. Indeed, more than 90% of the entire big vessel injuries emanate from an injury’s penetrating mechanism. In history, those injuries were evenly lethal. However, the present capability of quickly imaging the great vessels, and the thorax and carry out fast crisis surgical interference has significantly decreased the death rate. As a result of lung injuries being rife with thoracic penetrating trauma, they are capable of causing either hemothorax or, pneumothorax or both of them. Both tracheobronchial injuries and lung injuries can happen with the penetrating trauma. Those injuries are nearly always related to injuries that are associated with other structures, for example, the great vessels (Wilson, Grande, & Hoyt, 2007). The injuries of oesophagal are moderately few. However, they possess considerable lasting complications. The diaphragm muscle, which is separated by the thoracic cavity from the abdominal cavity, is commonly injured by the penetrating trauma to the trunk (abdomen and chest) (Wilson, Grande, & Hoyt, 2007). The occurrence of diaphragmatic injuries is roughly forty-five percent of gunshot injuries and fifteen per cent of stab injuries to the trunk. Body Systems That Must Be Addressed To Ensure They Are Functioning Properly The first body system that should be addressed is the spinal cord. The spinal cord is treated to determine whether it is injured or not to take instant spinal precautions. The second body part that must be addressed is the patient’s airway. In case a patient does not have a patent airway, the airway should be opened with manoeuvring the jaw-thrust to reduce additional injury of the spine (Caroline, 2010). In case, the patient’s airway is filled with fluid (possibly vomits or blood), the patient requires suctioning. The other body part that should be addressed is the noses to determine whether the patient is breathing. When the patient is not breathing, he should be offered two breaths and examination of the carotid pulse should be conducted. The breathing rate is also ascertained. The other body part that must be addressed is the chest. It is addressed to detect the possible life-threatening injuries such as flail chest or chest wound. The other part that ought to be addressed is the head to find out whether there are any injuries. The other body that must be addressed is the neck since high-risk structures including the jugular veins, oesophagus, spinal cord, and vertebral arteries among others pass through it. The other part that should be addressed is the lungs. Lung injuries are capable of causing hemothorax and pneumothorax or the combination of both. The other body parts that must be addressed are the pelvis and abdomen as they contain several organs and correlated structures (Caroline, 2010). The other body that must be addressed is the heart to ascertain the heart rates and possible injuries. 4 Hours Ago the Patient Had A Blood Pressure of 110/65- Explanation of Why the Patient Was Normotensive Principally, the blood pressure within the circulation is as a result of the heart’s pumping action (Moylan, 2007). Disparities within verge blood pressure are liable to the flow of blood from location to location. The mean blood flow rate is dependent on both the flow resistance and blood pressure presented by vessels of blood. Therefore, the patient was normotensive because there was enough blood and energy in the body for circulation purposes. The Concept of Permissive Hypotension Regarding Penetrating Injuries and Fluid Management Permissive hypotension also referred as hypotensive resuscitation is the utilisation of restricted fluid remedy. It is mainly used within the trauma victim and raises the methodical pressure of blood without attaining normotension or normal blood pressures (Joao, 2010). The aimed blood pressure for those patients is an average pressure of artery (40-50mmHg) or a systolic pressure of blood below or equivalent to 80. However, this is dependent on particular criterion of clinics. After a traumatic injury, some patients undergo hypotension which is caused by the loss of blood (haemorrhage), but other factors can also cause it. Recent research has revealed that there are advantages of permitting particular patients to undergo some amount of hypotension within specific settings (Joao, 2010). This concept of permissive hypotension includes remedy through vasopressors, inotropes and IV fluids. The only limitation is entirely avoiding normalising pressure of blood within the context that would enhance blood loss. The body commences natural coagulation procedure the moment a person starts bleeding. Eventually, the procedure discontinues the bleeding. Problems of fluid resuscitation with no bleeding control are regarded as secondary to an extrication of the thrombus (blood clot) which helps in controlling additional bleeding. Thrombus extraction was seen to happen at a systolic pressure larger than 80mm Hg (Joao, 2010). Additionally, fluid resuscitation dilutes factors of coagulation that assist in forming and stabilising clot. Thus, this makes it difficult for the body to utilise its natural measures to discontinue the bleeding. Hypothermia aggravates those factors. On the other hand, it is valuable to know that permissive hypotension is neither a substitute nor a treatment for the control of definitive haemorrhage. Since there is huge heterogeneity among patients with trauma with regard to mechanism (penetrating vs. blunt) and severity of the injury, this strategy requires careful selection. Conclusion Penetrative trauma is an injury (or injuries) which occur the moment the skin is pierced by an object thus, entering the body and creating an open sore. The patient is typically left bleeding profusely on the wounded part. Penetrating injuries are capable of causing harm to the heart, diaphragm, chest wall, great vessels, oesophagus, and tracheobronchial structures. Some of the important parts that require being addressed to ensure they are functioning in penetrative trauma include chest, lungs, neck, and heart among others. Such vital organs if left unchecked can cause serious trouble or even death of a patient. The availability of enough energy and blood in the body ensures the appropriate body pressure. Hypotensive resuscitation attempts to bring the regular blood pressure using the fluid therapy. References Caroline, N. L. (2010). Nancy Caroline’s Emergency Care in Streets. New York (N.Y.): Jones & Bartlett. Giffard, P. V. (2011). Penetrating Trauma. Oxford: Tort. Joao, B. R. (2010). Permissive Hypotension and Desmporessin Enhance Clot Formation. Journal of Trauma-Injury Infection & Critical Care. 68(1), 42-51. Moyln, et al. (2007). Association between a positive ED FST Examination and Therapeutic Laparotomy in Normotensive Blunt Trauma Patients. The Journal of Emergency Medicine. 33(3), 265-27. Scharff, J. R., & Nauheim, K. S. (2007). Traumatic Surgery Clinics. Thoracic Surgery Clinics. 17(1), 81-85. Wilson, W. C., Grande, C. M., & Hoyt, D. B. (2007). Trauma: Emergency Resuscitation, Perioperative, anaesthesia, surgical Management, Volume 1. Read More