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Patient Care

Shootings: What EMS Providers Need to Know

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   Firearm-related injuries continue to be a significant public health problem, accounting for almost 20% of injury-related deaths in the United States.1

   From January 1993 to December 1998, an estimated 115,000 firearm-related injuries occurred annually in the U.S. Males were seven times more likely to die or be treated in emergency departments for gunshot wounds than females. In 2006 more than 30,000 persons died from firearm injuries in the United States.2

   Gunshot wounds to the head are the most lethal of all firearm injuries.3 It is estimated they have a fatality rate greater than 90%. Those to the myocardium have fatality rates reaching 80%. Intra-abdominal injuries from gunshot wounds tend to involve the small bowel (50%), colon (40%), liver (30%) and abdominal vascular structures (25%).4

PENETRATING MOI

   Gunshot wounds involve the transfer of energy to a target. The damage that occurs is directly related to the amount of energy exchanged between the penetrating object and what it strikes, which relates to the projectile's mass and velocity. Other influencing factors include tissue density, the penetrating object's frontal area, and the distance between the weapon and the target.5–9

   When a bullet strikes a person, tissue is crushed. The bullet's forward movement creates a temporary tunnel that expands to a larger tunnel. The larger tunnel is considered to be a temporary "cavitation" wave. Tissues in the temporary cavity sustain damage from compression, deformation and shear. After a bullet passes through, the temporary cavity recoils to its normal position, but with a remaining cavitation, called the permanent cavity. Tissue of the permanent cavity may be damaged and nonviable. Secondary missiles, such as bullet and bone fragments, can result in additional damage.5–9

   Penetrating mechanisms of injury can be described as low, medium or high velocity. Damage from low-velocity mechanisms, such as stabbings, is often limited to the structures directly contacted. Medium-velocity mechanisms, like bullets from most types of handguns, produce less tissue destruction than high-velocity forces. High-velocity mechanisms include shots from rifles and larger military weapons.5–9

   Bullet design varies. Some are encased with hard "jackets," typically copper, to prevent the lead inside from deforming against a target. This promotes deeper penetration. Bullets that deform or fragment, such as those with soft or hollow points, may ricochet inside the body. Factors that can influence this include the location of the bullet's entry and the distance between the weapon and the victim when the weapon was fired.5–9

   Shotguns have shells containing small spherical pellets (shot) or items such as slugs or flechettes. These contents spread apart as they leave the barrel, distributing the blast energy over a wider area. At close range shotgun injuries can be more severe than bullet injuries. At greater range, the wider spread and lower velocity of the pellets tend to produce separated and superficial injuries.7

ENTRY, EXIT

   Gunshots may create both entrance and exit wounds. Entrance wounds tend to have a round shape with a surrounding margin of abrasion. Contact wounds occur when a firearm is held directly against the body, and can include a muzzle imprint and soot on the skin. Close- or intermediate-range wounds may have a wider zone of powder stippling. Distant-range wounds tend to lack powder stippling and may have holes roughly equal to the caliber of the projectile fired.8,9

   Exit wounds can have a variety of appearances, including round, oval, slitlike, stellate or crescent. They may be larger than entrance wounds if the bullet expanded or tumbled on its axis, but most likely won't have gunshot residue. If an exit wound was abutted by firm support, such as clothing or furniture, it may have a circular defect and abraded margin resembling an entrance wound.8,9

   It is not always possible in the prehospital setting to determine if a wound is an entrance or exit wound. Refrain from documenting opinion, and allow forensic experts to make the determinations. Most shooting scenarios are crime scenes, and critical conclusions may be based on such interpretations. It is more important for EMS providers to identify and locate wounds and quickly manage patients. Taking the time to speculate on wound trajectory may delay the delivery of care, be detrimental to the patient's outcome and disrupt professional forensic conclusions and/or criminal prosecution.8,9

   When a bullet enters the body, numerous factors influence its path and subsequent injuries. The bullet may deform or fragment and contact more than one bone or organ. Structures that are less dense and have elasticity may sustain less damage than structures with greater density and more rigidity. For example, lung tissue has low density with high elasticity and tends to be less damaged than muscle with higher density and some elasticity. The liver, spleen, brain and adipose tissue have little elasticity and are easily injured. Organs that are fluid-filled, such as the bladder, heart, great vessels and bowel, may rupture due to pressure waves even without direct contact by the missile. If a bone is involved, a secondary missile may form and cause additional injury.8,9

SCENE RESPONSE

   Shooting scenes may range from single victims with assailants no longer present to mass-casualty incidents or ongoing crime scenes with active shooters.11 Providers responding to them should work to maximize their situational awareness—what's happened, what's known, and what they might find on scene.

ARRIVAL, TRIAGE

   When arriving at the scene, consider the following: Is the scene secure or active? Is law enforcement present? Has a shooter been caught? How many patients are there? What is their status? What additional resources are needed? Should ICS be initiated? What is the status of local EDs? What is the status of the system's surge capacity? Should a supervisor be updated? Should body armor be donned? Where should initial responders stage? What's the best entry and exit? Is online medical control available? Is on-scene medical control by a physician needed? Should a mass-casualty plan be activated?10–16 Providers must be familiar with local protocols and guidelines regarding management of gunshot wound patients, and should also be familiar with their local mass-casualty incident (MCI) plans.

   When the first responding unit arrives, responders should establish command and begin an overall assessment or size-up. Using an incident command system is beneficial. ICS supports the integration of facilities, equipment, personnel, procedures and communications.16

   Limit providers entering the scene to the number necessary to immediately care for the patient. If a victim, including a fatality, needs to be moved to allow access to other viable patients, do it with respect to the fact that it is likely a crime scene.

   In multiple-patient situations, it is likely more than one response organization will be involved. Establish a chain of command as soon as possible. Use common terminology whenever possible to avoid confusion, both on the radio and in person.15

   Hostage and active shooter scenarios present unique challenges. Involvement of law enforcement is essential. Providers' personal safety always takes priority. EMS may be asked to stage and stand by for additional instructions. If providers are in a secure area, they should focus on caring for patients and not be hindered by whatever else is happening. If possible, the preservation of evidence will be appreciated.

   The first-arriving providers to a shooting will need to start triage. This process can be difficult even for veteran providers. Patient access, availability of resources, communication effectiveness and the ability to conduct accurate initial assessments are just some of the challenges. Be as accurate and thorough as possible.17

   There are numerous triage systems, tools and vendors available. Some systems use colors or priorities based on the patient's overall condition (e.g., red for immediate, yellow for delayed, green for minor, black for unsalvageable). Others use a two-stage approach where responders instruct patients to walk to a specific location for additional assessment. Patients who are unable to follow this direction require further triage, usually using an approach similar to the color/priority system.11–13,18 A third technique is the CUPS system, which classifies patients as C for critical, U for unstable, P for potentially unstable or S for stable.19

RAPID PATIENT ASSESSMENT

   When triaging gunshot wound victims, rapid patient assessment to identify life-threatening injuries is essential. Critical interventions may include airway management, pleural decompression, pressure for external hemorrhage and avoiding on-scene delays before transport.20

   A rapid patient assessment can be done in less than 60 seconds. In a critical gunshot wound situation, it may not be necessary, for example, to pause after opening the patient's airway to determine what intervention should be considered. Rather, once the airway is open, the patient's respiratory quality, effort and effectiveness can be quickly assessed. Providers can simultaneously begin to determine the next steps for assessment and treatment.

   The acronym ABCDE is useful for rapid assessment. The components can be accomplished quickly and often simultaneously.19–22

   Airway—If the patient's airway is unstable or at risk, intervention is critical. It may need to be opened using a manual modified jaw-thrust, especially if cervical spine injury is suspected. Additional management may include use of a nasopharyngeal, oropharyngeal or advanced airway. Early airway management can be lifesaving where there has been a gunshot wound to the neck and an expanding hematoma. In this situation, the airway can become extremely difficult to manage very quickly. Use airway management techniques and adjuncts in accordance with local protocols.19–22

   Breathing—As the patient's airway is opened, evaluate breathing and respiratory effort simultaneously. Observe respiratory rate, quality and depth, and note accessory muscle use.19–22 Assess breath sounds as soon as practical. Depending on the situation, providers may want to perform auscultation after palpating the thorax, as palpation may reveal tenderness and/or crepitus. Palpate with caution to avoid injury from possible bullet fragments.21–23

   Circulation—Circulation can be quickly assessed using common pulse locations. Evaluate for presence, rate, regularity, strength and quality. Pulses may also be used to estimate blood pressure (though this is debated in the literature). For example, in an adult patient, the presence of a radial pulse is considered to correlate with an approximate systolic BP of at least 80 mmHg. The presence of a brachial or femoral pulse is associated with an SBP of 70 mmHg, and a carotid pulse is associated with one of 60 mmHg.21,22 Consult your local protocols regarding the use of such approximations.

   The skin can also be used to assess circulation. Skin is normally warm, pink and dry to the touch. Abnormal findings include skin that is cool, pale, gray and/or moist.21,22 Capillary refill time can be evaluated for a quick assessment of peripheral circulation.

   Disability/neurological—Perform a rapid assessment of the patient's neurological status as soon as possible. This can be evaluated using the AVPU system (alert, responsive to verbal stimuli, responsive to painful stimuli, unresponsive). The Glasgow Coma Scale can also be used (see Table 1).21,22 Evaluation of neurological status includes identification of paralysis. A rapid evaluation may include assessing the patient's ability to squeeze equally with both hands and equally move both legs. An early neurologic assessment can be important, particularly for comparison with later assessments.

   Expose—Expose the patient to allow rapid visual inspection of the body. This is especially important with gunshot wound victims, as clothing or other items may cover wounds. Inspect for external hemorrhage, abrasions, lacerations, burns, penetrating injuries, bruising and other abnormal findings. When removing clothing, avoid cutting through any holes if possible, as they might represent evidence. Do not discard clothing. Leave it on scene or transport it with the patient for evidence collection.21,22

   In a gunshot wound scenario, the provider's ability to reach a patient, perform an initial rapid assessment, identify obvious external injuries, suspect potential internal injuries and form a treatment plan within seconds is critical. With this in mind, consider any patient with a gunshot wound to the head, neck, chest, abdomen, pelvis or thigh to have a potentially life-threatening injury until proven otherwise. Depending on the scenario and resource availability, these cases may justify immediate intervention.21,22

FOCUSED ASSESSMENT

   After performing the initial rapid assessment, the provider may, time permitting, perform a more detailed head-to-toe assessment. This should begin with a visual inspection, followed by hands-on assessment.

   Head—When assessing the head, look for possible signs of trauma. While palpating the face and sides and back of the head, feel for skull deformity, crepitus or the presence of fluids such as blood or other tissues. Inspect the nose and ears for deformity and fluids. Check pupils for size and reaction. Do not assess the oculocephalic or oculovestibular reflexes in the prehospital setting.19

   Neck—Neck anatomy includes major blood vessels, airway anatomy, the esophagus, the cervical spine and the spinal cord. In the prehospital setting, a gunshot wound to the neck, regardless of external appearance, should always be considered potentially life-threatening.21,22,24,25

   Begin assessment with visual inspection. Observe for bruising, wounds, lacerations or hematomas. Note the appearance and alignment of the trachea and if the jugular veins appear normal or distended. When palpating, note deformity or crepitus. Does the patient appear to be in respiratory distress, with tracheal tugging?21,22,24,25

   Chest—Begin with visual inspection and observe the rise and fall of the chest, including symmetry, presence of bruising, open wounds and hemorrhage. When palpating, be observant of equal chest rise and fall, accessory muscle use to breathe, crepitus and overall integrity. In the patient with penetrating chest trauma, perform a rapid yet thorough search for additional wounds.21–23,26,27 Auscultate breath sounds. Abnormal findings can include crackles, wheeze, rhonchi or absent breath sounds.21–23

   A penetrating wound to the anterior, lateral or posterior chest, including the armpits, should be considered life-threatening until proven otherwise. In addition, a gunshot wound to the chest should never be considered isolated to a single organ or system. The path of the bullet within the thorax cannot be determined in the field. It may have ricocheted, causing a variety of injuries. Examples include hemothorax, pneumothorax, hemopneumothorax, diaphragmatic rupture, pulmonary contusion, rib fracture, subcutaneous emphysema, pneumomediastinum, thoracic wall lacerations and sternal fracture.26,27

   If two or more gunshot wounds are present, assume substantial internal damage. This is important to note, as patients with combined intrathoracic and intra-abdominal injuries have a greater chance of dying.21,22,26,27

   Abdomen—Inspect the abdomen for symmetry, bruising, distension and open wounds. Abdominal distension may suggest intra-abdominal bleeding. When palpating, begin with gentle and shallow pressure. Consider guarding or self-splinting by the patient potential signs of internal injuries.4,5

   When anticipating potential injuries, the abdominal region may be divided into quadrants. Visualize median and transverse planes that pass through the umbilicus at right angles. This divides the abdomen into four quadrants. Table 2 provides an overview of the organs within each quadrant.4,5,21,22

   A high level of suspicion is necessary with penetrating abdominal wounds. Hemodynamically stable patients with penetrating abdominal trauma may have hollow or solid organ injury. Solid organ injury may include extensive hemorrhage; hollow organ injury can involve hemorrhage as well as the spillage of gastrointestinal contents. Hypotension, a narrow pulse pressure and tachycardia suggest serious intra-abdominal injury.4,5,21,22

   In a conscious patient, pain, guarding and rebound tenderness may indicate abdominal bleeding. In an unresponsive patient, abdominal distension and bruising may be the only indications of internal bleeding. Potential internal bleeding should be considered if the patient is unresponsive, has a distended/bruised abdomen, or is tachycardic or hypotensive. Penetrating injuries to the flank or retroperitoneal area may involve the duodenum, pancreas, kidneys, ureters, bladder, colon, major abdominal vessels and rectum.4,5,21,22

   Pelvis—Inspect the pelvis for signs including open wounds, bruising, deformity and hemorrhage. Palpate for instability. Penetrating wounds to the pelvic area should be assumed to involve other areas of the body as well until proven otherwise.19

   Extremities—Evaluate the extremities for wounds, hemorrhage, crepitus, deformity and mobility. Note potential circulatory compromise (absence of distal pulses either from direct injury or hypotension from hemorrhagic shock) and neurological impairment (inability to sense distal stimuli). Evaluate the extremities' skin for color, temperature, turgor and bruising.21,22

   The symptoms of a gunshot wound will be influenced by numerous factors, including the type of weapon involved, type of projectile, where the patient was shot, organs/systems involved, the patient's overall condition, substance abuse and baseline health. Table 3 provides examples of symptoms that might be encountered.21,22

   Monitor and reassess vital signs throughout the incident. If they're available and time allows, apply cardiac monitoring and pulse oximetry. Changes in vital signs, including pre- and post-fluid bolus administration, should be documented and reported to the receiving hospital. When possible, obtain the patient's medical history, but do not invest excessive time.21,22

TREATMENT

   The prehospital management of patients with gunshot wounds may vary, but will focus on supportive care and rapid transport. As an initial step, since any compromise to perfusion will directly affect oxygen delivery, give supplemental oxygen early.

   Management of a gunshot wound to the head may include airway management and direct pressure for external hemorrhage. Depending on the mechanism and anatomy involved, airway management may be challenging. Adjuncts, including suction, should always be available. Although cervical spine immobilization may be indicated in select cases, the literature has not found a clear benefit to immobilizing victims of penetrating trauma, and recent studies have suggested possible harm. Consult your local protocols.19–22

   Management of a gunshot wound to the neck will be influenced by numerous factors. Providers may need to address active external hemorrhage, potential internal hemorrhage, tracheal compromise resulting in airway compromise, and open penetrating neck wounds. External bleeding may require direct pressure. An open wound may require application of an occlusive dressing. Tracheal involvement may require advanced airway procedures such as intubation through the penetrating neck injury. C-spine immobilization may be indicated.20,21,24,25

   With a gunshot wound to the chest, patient management will depend in part on the suspected injury. Providers will need to consider the reported mechanism of injury, potential for internal injury, potential for internal and external blood loss, and patient's overall condition. If the patient has sustained an open chest wound, an occlusive dressing may be needed.20,21,26,27

   These patients may have a variety of internal thoracic injuries. In cases of tension pneumothorax or tension hemopneumothorax, immediate intervention is indicated. Many EMS systems allow providers to perform chest decompression with needle thoracostomy. The technique involves inserting a large-bore catheter in the anterior chest between the second or third intercostals margin of the ribs on the affected side or between the fourth and fifth ribs laterally at what is often referred to as the midaxillary line. Once the catheter has been introduced, air is released from the thorax, and the pressure within becomes equalized. This allows for improvements in air exchange and circulation.20–22

   With penetrating thoracic trauma, consider fluid administration. Fluid selection, rate of administration and the amount administered will depend on local protocols, provider judgment and the patient's overall condition. There is still controversy regarding the ideal goal for a blood pressure in the shooting victim. Some say higher blood pressures promote bleeding from injury sites; others argue permissive hypotension may compromise adequate perfusion. A summary of the current literature suggests a SBP of at least 90 mmHg, but not a lot higher, is a reasonable goal. The type of fluids to use is also the subject of debate. At this time, the literature best supports crystalloid solution (normal saline or lactated Ringer's) for these patients.19–21,28

   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

Table 3: Gunshot Wound Signs & Symptoms
Injury location Signs & symptoms
Head External bleeding, deformity of the head, fluid in the ears/nose
Neck External bleeding, tracheal shifting, deformity, JVD, tracheal tugging, bruising, crepitus, raspy voice
Tracheobronchial/lung Subcutaneous emphysema, cough, respiratory distress, hemoptysis (usually secondary to a disrupted bronchial artery), tension pneumothorax, intercostal retractions, decreased breath sounds, hyperresonance, tachypnea, agitation, hypotension, tachycardia, hypoxia, shifting of the trachea and apical heartbeat away from the injured side
Carotid artery Decreased LOC, contralateral hemiparesis, hemorrhage, hematoma, dyspnea (secondary to compression of the trachea), pulse deficits
Jugular vein Hematoma, external hemorrhage, hypotension
Esophagus, pharynx Dysphagia, bloody saliva, sucking neck wound, pain and tenderness in the neck, crepitus
Abdomen Bruising, distension, rigidity, external hemorrhage, self-splinting
Pelvis Bruising, external bleeding, deformity, crepitus
Extremities Bruising, open wound, external bleeding, crepitus, deformity, decreased or absent distal pulse, reduced or absent sensation, delayed capillary refill time

References

1. Gotsch KE, Annest JL, Mercy JA, Ryan GW. Surveillance for fatal and nonfatal firearm-related injuries—United States, 1993–1998. MMWR 50(SS02): 1–32, Apr 13, 2001.

2. Heron M, Hoyert DL, et al. Deaths: Final data for 2006. National Vital Statistics Reports 57(14), Apr 17, 2009.

3. New York-Presbyterian Hospital. Cranial Gunshot Wounds, http://nyp.org/health/cranial-gunshot-wounds.html.

4. Testa PA, Legome E. Abdominal Trauma, Penetrating. http://emedicine.medscape.com/article/822099-overview.

5. Stanton-Maxey KJ, Bjerke HS. Abdominal Trauma, Penetrating. http://emedicine.medscape.com/article/433554-overview.

6. Evans MB. Gunshot Wound Ballistics. www.bcm.edu/oto/grand/02_12_04.htm.

7. Coustan D. How Shotguns Work. HowStuffWorks, http://science.howstuffworks.com/shotgun11.htm.

8. Denton JS, Segovia A, Filkins JA. Practical pathology of gunshot wounds. Arch Path & Lab Med, Sep 2006, http://findarticles.com/p/articles/mi_qa3725/is_200609/ai_n16717329/pg_3/.

9. University of Utah, Spencer S. Eccles Health Sciences Library. Firearms Tutorial, http://library.med.utah.edu/WebPath/TUTORIAL/GUNS/GUNINJ.html.

10. U.S. Coast Guard. Team Coordination Training Student Guide, Situational Awareness. www.uscg.mil/auxiliary/training/tct/chap5.pdf.

11. Triage. http://en.wikipedia.org/wiki/Triage.

12. Triage tag. http://en.wikipedia.org/wiki/Triage_tag.

13. Field Triage Decision Scheme. www.cdc.gov/FieldTriage.

14. Barishansky RM, Langan J. Surge capacity: Is your system prepared for the victims of a large-scale incident? EMS Magazine 38(4): 36–40, 2009.

15. Cotter S. Mass-casualty response: The vital first few minutes. EMS Magazine 38(4): 29–34, 2009.

16. Incident Command System. www.fema.gov/emergency/nims/IncidentCommandSystem.shtm.

17. Ashkenazi I, Kessel B, Khashan T, et al. Precision of in-hospital triage in mass-casualty incidents after terror attacks. Preh Dis Med 21(1): 20–3, Jan-Feb 2006.

18. Chames V. Disaster First Aid, START Rapid Triage. Oakland, CA: Darkhorse Press, www.disasterfirstaid.com/rapidtriage.html.

19. Hubble M, Hubble J. Principles of Advanced Trauma Care. Albany, NY: Delmar Thompson Learning, 2002.

20. Dries DJ. Initial Evaluation of the Trauma Patient. http://emedicine.medscape.com/article/434707-overview.

21. Miglietta MA. Trauma and gunshot wounds: What you need to know to save a life. www.tacticalmedicalpacks.com/files/Combat_Tactics_Trauma_article.pdf.

22. Chapleau W, Burba A, Pons P, Page D. The Paramedic. Boston: McGraw-Hill, 2008.

23. Rathe R. Examination of the Chest and Lungs. University of Florida Office of Medical Informatics, http://medinfo.ufl.edu/year1/bcs/clist/chest.html#AA13.

24. Levy DB, Gruber BS. Neck Trauma. http://emedicine.medscape.com/article/827223-overview.

25. Alterman DM, Daley BJ. Penetrating Neck Trauma: Treatment. http://emedicine.medscape.com/article/433306-treatment.

26. Shahani R, Galla JD. Penetrating Chest Trauma. http://emedicine.medscape.com/article/425698-overview.

27. Lloyd D. Thoracic Trauma, www.doh.wa.gov/hsqa/emstrauma/OTEP/thoracictrauma.ppt.

28. Armstrong B. Permissive Hypotension. Trauma.org, www.trauma.org/archive/resus/permissivehypotension.html.

   Paul Murphy, MSHA, MA, has administrative and clinical experience in healthcare organizations.

   Chris Colwell, MD, is medical director for the Denver Paramedics and an attending physician in the emergency department at Denver Health Medical Center.

   Gilbert Pineda, MD, FACEP, is medical director for Rural/Metro (Aurora, CO) and an attending ED physician at The Medical Center of Aurora and Denver Health Medical Center.

   Tamara Bryan Murphy, PA-C, MMS, is an emergency department physician assistant with Kaiser Permanente and Centura Health (Denver/Littleton, CO).

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