06.iv • Ballistic injuries

Approach to ballistic injuries – for use in the pre-hospital phase

Interventions

<C>ABCDE appoach

Penetrating head injury

Low GCS = airway at risk:
lateralising signs = need surgical assessment

Airway injury

• above cricothyroid membrane: think cricothyroidotomy
• below cricothyroid membrane: think tracheostomy

Chest

Pneumothorax?
Haemothorax?

Abdomen

Internal bleeding?
Emergency theatre
Consider need for NG tube

Limbs

Haemorrhage control
If appropriate to re-examine wounds prior to surgery, redress with iodine-soaked gauze and secure with crepe bandage.
Splint long bone injuries
Analgesia

Fluid resuscitation


Critical decisions

Identify time critical injuries (non-compressible haemorrhage) requiring urgent surgery

Caveats

  • check front and back of casualty
  • bullets and fragments cross cavities


Approach to ballistic injuries – for use in ED

Interventions

<C>ABCDE appoach

Penetrating head injury

Follow guidelines for pre-hospital phase plus consider RSI, obtain CT, antibiotics

Airway injury

• above cricothyroid membrane: think cricothyroidotomy
• below cricothyroid membrane: think tracheostomy; move to emergency surgery

Chest

Follow guidelines for pre-hospital phase plus antibiotics

Abdomen

Internal bleeding? Confirm with FAST USS or DPL. Antibiotics

Limbs

Follow guidance for pre-hospital phase
Antibiotics:
Co-amoxiclav 1.2g 1V
If penicillin allergic:
Vancomycin 15mg/kg 1V
+ Ciprofloxacin 200mg 1V
+ Metronidazole 500mg 1V

Fluid resuscitation
Antibiotics
Tetanus prophylaxis for the non-immune
Urinary catheter with hourly measurement for critical patients


Critical decisions

Consider absolute requirement for surgery

Decision must be tempered by patient’s condition and anticipation of further inbound patients Investigations

Investigations

  • FBC
  • cross match blood
  • blood gases for critical patients
  • urea and electrolytes where indicated
  • plain radiology/USS/CT where indicated