Shootings: What EMS Providers Need to Know

   Treatment of a gunshot wound to the abdomen may include bandaging, direct pressure and use of an occlusive dressing. The location of the wound and patient's overall condition will influence specific treatment, including fluid administration. As with thoracic trauma, fluid selection, rate of administration and amount administered will rely on local protocols, provider judgment, and overall condition.^4,5,20,21

   Treatment for gunshot wounds to the extremities will vary. With a suspected fracture, immobilize per local protocols. In many cases pain relief will be indicated. Manage open extremity wounds and external hemorrhage with direct pressure and bandaging. Consider penetrating trauma in the midfemur or higher to be life-threatening until proven otherwise.^20,21

   With gunshot wounds to the head, neck, chest, abdomen, pelvis or thigh, establish at least one intravenous line. Fluid options may include crystalloids, colloids and blood substitutes. Hypertonic crystalloid solutions, such as hypertonic saline/dextran and hypertonic saline, have been considered as well. The literature has not shown advantages to hypertonic saline or colloid solutions in trauma patients, so crystalloids appear to be a reasonable approach at this time.^19,20,22

   Administer fluids by local protocols. Aggressive IV fluid administration to maintain or reach normotension is discouraged in patients with penetrating injury unless the patient manifests severe shock or prolonged transport is expected. There may be select cases in which permissive hypotension is preferred over fluid administration intended to maintain a normal blood pressure.^4,28

   Whenever possible, prevent the patient from cooling to the point of shivering. When clothing is removed and IV fluids are administered, hypothermia can be induced. Prewarmed blankets and fluids may help avoid this. While there is research looking at the potential benefit of hypothermia in certain cases, intentionally inducing prehospital hypothermia on penetrating trauma patients is not an agreed-upon standard of care.^20,21

   Contact the receiving hospital(s) as soon as possible. Early notification can play a critical role in ensuring timely and appropriate resources are available for your patient. Items to communicate include the number of patients, types of injuries and potential injury severity. Protocols should be clear regarding which hospitals are capable of managing gunshot wound victims.¹⁹

Table 1: GCS

   Eye opening

   4 = Spontaneous

   3 = To voice

   2 = To pain

   1 = No response

   Verbal response

   5 = Oriented (person, place, time, event)

   4 = Confused

   3 = Inappropriate words

   2 = Incomprehensible words

   1 = No response

   Motor

   6 = Obeys commands

   5 = Localizes pain (purposefully tries to stop painful stimuli)

   4 = Withdraws from pain (moves away from painful stimuli)

   3 = Abnormal flexion to pain (decorticate posturing)

   2 = Abnormal extension to pain (decerebrate posturing)

   1 = No response

Table 2: Abdominal Anatomy, Location

   Left upper quadrant—Spleen, pancreas, stomach, kidney, colon

   Right upper quadrant—Liver, gallbladder, pancreas, duodenum, kidney, colon

   Right lower quadrant—Appendix, ascending colon, small intestine, ovary, Fallopian tube

   Left lower quadrant—Small intestine, descending colon, ovary, Fallopian tube