Tia Dickson, RN, BSN

Primary Children's Hospital

Stop the Bleed

Stopping the bleeding is a crucial part of managing a gunshot wound. Minutes count! Someone who is severely bleeding can bleed to death in as little as five minutes. There is an incredible course developed by the American College of Surgeons set up to train you and your community about how to Stop the Bleed and it's free. Find out more on their website https://www.stopthebleed.org/

• Place strong pressure on the wound: If blood is coming out of a hole, put a lot of pressure on it.
• Dress the wound: Dressings help the blood to clot and seal the wound. Use whatever is available.
• Use a tourniquet if you can: Professional tourniquets are great, but using them properly takes practice. It should be very uncomfortable if it's on correctly—maybe even painful. Improvised tourniquets often fail.

Treating Different Types of Wounds

Gunshot wounds are puncture wounds. Don't expect to be able to tell the difference between entrance and exit gunshot wounds. Refrain from documenting opinion and allow forensic experts to make the determinations. Someone who has had a gunshot wound might also have substantial internal injuries. Difficulty breathing, low blood pressure, and heart effects are common. Begin high quality CPR if the patient is not breathing and doesn't have a pulse.

Chest Injuries

Chest wounds can injure the heart, lungs, and/or aorta. In some cases, a gunshot wound to the chest can be a seal-sucking wound that creates a pathway for air to enter the chest.

For gunshot wounds to the chest, seal the wound with some type of dressing (plastic works well) to keep air from being sucked into the wound. This helps prevent the development of a collapsed lung. If the patient begins complaining of worsening shortness of breath after you seal the wound, remove the seal.

Abdominal Injuries

A gunshot wound to the abdomen can cause severe bleeding, as well as organ damage and abdominal wall damage. A wound that punctures the stomach or intestines can lead to an infection. You might notice rapid swelling of the abdomen, even with a relatively small puncture wound.

For abdominal gunshot wounds, be sure to hold pressure on the wound. Emergency surgery is generally necessary.

Limb Injuries

A gunshot to a limb is likely to cause a vascular injury, and may also cause nerve damage or broken bones.

Avoid unnecessary movement of the limb. Prevent blood loss by holding pressure or applying a tourniquet.

Neck Injuries

A gunshot wound to the spine can cause paralysis, and a wound to the front of the neck can damage the carotid artery, potentially preventing blood from reaching the brain.

Maintain C-spine to prevent damage to the spinal cord. And if someone was shot in the front of the neck, hold pressure to prevent bleeding.

Injuries from Nonpowder Firearms (BB, pellet, paintball, and airsoft guns)

BB and pellet guns are a leading cause of gun-related injuries in children and adolescents. Many victims suffered severe and long-lasting injuries, such as perforated bowels or damage to lungs, heart, and eyes. In most states, BB guns, pellet guns, and paint ball guns are not considered firearms because they use gas, springs, or compressed air and not gunpowder to shoot projectiles. But modern day air guns are much more powerful than in the past. While deaths are rare, they do occur and these "toys" can penetrate the skin and cause organ damage. Treatment of these injuries is the same as other firearm injuries.

Understanding Bullet Wounds

Gunshot wounds are not straightforward, and they can cause injuries beyond the visible puncture site. Bullets can bounce around inside a person's body, and various dynamics affect their path. A bullet can remain in the body, or it can exit after doing substantial damage.

The physical damage caused by a gunshot injury depends on several key factors:

• Location of the injury
• Size of the projectile
• Speed of the projectile

While all of these are important, the speed of the bullet is the most significant factor on the amount of damage done by the round.

Rifles, for example, produce significantly faster-velocity projectiles than handguns, and therefore typically cause more severe injuries. That's not to say handguns are not dangerous; just that rifles are generally even more dangerous.

For an in-depth review of scene response read here:

SCENE RESPONSE

References

https://www.verywellhealth.com/how-to-treat-a-gunshot-wound-1298915

Gun Safety and Children

https://www.mottchildren.org/posts/your-child/gun-safety-and-children

Firearms are a significant cause of injury and death in the United States. Studies have shown that one in three homes with guns also have children in the home.

The American Academy of Pediatrics (AAP) believes, “the absence of guns from children’s homes and communities is the most reliable and effective measure to prevent firearm-related injuries in children and adolescents.”

Current medical research on the subject has concluded that if you have children, it is safer not to have a gun in your home.

For families who choose to keep guns in the home, there are steps you can take to reduce the risk of firearm injury or death.

Gun storage

For those who keep a gun in the home, each of the following four measures helps protect children and teens from accidental firearm injury and suicide:

• Keep the gun unloaded
• Keep the gun locked
• Store the ammunition locked and in a separate place from the gun
• Never let children know where the keys are located

Children, even older children, should not be told about the location of the keys.

There are programs available for free safety kits. Another option is to disassemble the gun so that it cannot be used (i.e., remove the bolt from a hunting rifle or the pistol slide on a handgun).

If there are concerns about mental illness, then it is safest to remove all firearms from the home to prevent any tragedies.

Guns at homes of others

Before your child goes to a friend's house you should ask the friend's parent whether the family has firearms in the house and how they are stored. This can be part of all the usual things you would discuss before a visit, like allergies, snacks, sunscreen, etc. The AAP offers suggestions on questions families should ask at Asking Saves Kids (ASK).

If your friends or family keep a firearm, urge them to keep it locked and unloaded.

Adolescents, Teens and Guns

Parents of teenagers are less likely to store firearms safely. This is a big concern since most firearm injuries happen to teens. Teens are at greater risk for attempting suicide and a suicide attempt with a gun is likely to be deadly. More than 90 percent of suicide attempts with a gun are deadly and teens in homes with firearms are at higher risk for committing suicide. Again, if there are concerns about mental illness, then it is safest to remove all firearms from the home to prevent any tragedies.

Teach children what to do in the presence of a gun

Teach your children never to touch guns. Parents can also talk about how a child might ask to go home or call a parent if they become aware of a gun in their presence.

Unfortunately, a number of studies suggest that even kids who are trained not to touch guns can't resist the curiosity, and parents have unrealistic expectations about their kids' behavior around guns. That's why parents are encouraged to keep guns unloaded and locked separately from ammunition, and to ask about guns at the houses where their children play.

Non-powder guns, BB guns and toy guns

Non-powder guns such as ball-bearing (BB) guns, pellet guns, air rifles, and paintball guns can cause serious injuries to children and teens.

• Pellet and BB guns are high powered and can easily injure or kill a child. They should be used only under adult supervision. The Consumer Products Safety Commission recommends only kids 16 years of age or older use BB guns.
• Parents may underestimate the potential for injury from BB and pellet guns unless their child has been wounded by one.
• Playing with toy guns could make it easier for your child to mistake a real gun as a toy.
• Police officers may also mistake a toy gun for a real gun. Toy guns should not look like real guns and should always retain the orange cap on the barrel.
• Toy guns with projectiles, such as Airsoft guns and paintball guns, can cause eye injuries, including severe and permanent vision loss. Kids should wear eye protection when using them.
• Make sure the firing sound is not too loud as it could damage your child's hearing. Children should wear hearing protection. Don't let kids fire cap guns closer than one foot from their ears, and only use them outdoors.
• Don't let kids put caps from toy guns in their pockets. They can ignite and cause burn injuries.

Additional resources:

• 6 strategies for keeping kids safe from gun accidents
• Parents more confident that tweens can deal with fire and storms than guns
  
• Gun safety for parents (kidshealth.org)
• Gun safety for kids (kidshealth.org)
• Someone at school has a weapon. What should I do? (kidshealth.org)
• Gun safety tips (safekids.org)
• ASK campaign (askingsaveskids.org)
• What do boys do when they find a real gun? (AAP)
• "They're Too Smart for That": Predicting what children would do in the presence of guns (AAP)
• Teaching firearm safety to children: Failure of a program (NIH)
• A firearm safety program for children: They just can't say no (NIH)
• Preventing Teen Suicide: When to Remove Firearms from Your Home (Michigan Medicine Health Blog)

Greg Nelsen, PharmD

From a pharmacy perspective regarding a gun shot wound victim, four things come to mind.

• Tranexamic acid (TXA) to help with bleeding
• Pain medication and treatment (easily forgotten in the adrenalin of the moment)
  
• Limiting crystalloids and using blood for fluid resuscitation when available
• Antibiotics to treat contamination of the wound

TXA is something commonly misunderstood by clinicians. They believe it helps stop bleeding but this is not quite true. The best way to think of it is a blood bank sparing medication. It does not promote clot formation or cause a hypercoagulable state. TXA works by making a reversible complex that inhibits plasmin formation and displaces plasminogen from fibrin. Basically, it helps to preserve the blood clots the body creates by inhibiting the breakdown of the clot, or fibrinolysis. This helps decrease the amount of bleeding the patient will have. For those >14 years old or 65 kg, give Tranexamic Acid (TXA) 1 gram IV once over 10 min if within three hours of blunt or penetrating trauma. Those at high risk of ongoing internal hemorrhage or significant external bleeding, who meet the following:

• Injury sustained within three hours prior to administration. TXA must be administered within three hours of the injury. Administer as early as possible following gross bleeding control and other lifesaving interventions.
• Systolic BP < 90mmHg and signs of ongoing hemorrhage, AND/OR
• Tachycardia > 110 bpm with signs of hypoperfusion (altered mental status, pallor, cool extremities) and signs of ongoing hemorrhage.

• Also indicated for excessive hemorrhage following delivery or delayed placenta delivery if within three hours of delivery

• Injuries > three hours old
• Patients < 14 years of age.
• Known hypersensitivity to drug

Precautions:

• Notify receiving hospital of TXA administration.
• Clearly document mechanism of injury, time injury/incident occurred, indications for administration, and time of administration of TXA.
• TXA should NEVER be administered at a “wide open” rate.

Adverse Effects: Hypotension (with rapid IV injection), seizures in high doses (>2-10 grams), allergic dermatitis, diarrhea, nausea, vomiting, blurred vision.

Dose: Mix 1g/10 ml of TXA in 100ml NS. Infuse over 10 min.

Pain medications for a penetrating wound are your usual suspects of fentanyl, morphine, and pain dose ketamine if needed.

• Fentanyl 1 mcg/kg (max 50 mcg per dose) IV/IM/IO. Use 2 mcg/kg for IN (intranasal) (max 100mcg per dose). May repeat x 1 if needed after 10-15 min
• Morphine Sulfate 0.1 mg/kg (max of 4mg per dose) IV/IM/IO titrated to effect

• Ketamine 0.15-0.3 mg/kg (max 30mg) diluted in 100mL of normal saline IV/IO infused over 15 minutes ONLY FOR USE in patients older than age two.

Caution should also be used with crystalloids when doing fluid resuscitation in trauma patients. Recent data has shown that overuse of crystalloids have worse outcomes when compared to using blood products for the primary fluid replacement. Also discuss with your medical control about permissive hypotension with your traumatic injury patient.

The choice of antibiotics will vary depending on the location of the wound and the severity of the injury. Antibiotic choice should follow your local antibiotic steward guidelines but should be given when available.

Our statewide Handtevy app was recently used during an EMS response to a 12-year old in full arrest. We asked a few questions to find out how it went.

What were the general circumstances of the call?

The call we utilized this on was a cardiac arrest of a 12-year old autistic male who was left in a hot vehicle for multiple hours. The initial call came in as a 9-year old male so that is what age we went with on the Handtevy App.

How was the app used? Multiple users, a team lead, etc?

The Handtevy App was pulled up by the lead paramedic on the ambulance while responding to the incident. Based on the age of the child and type of incident, the lead medic (passenger) relayed the information to his partner concerning what would be pertinent as they first arrived.

How did it go? Results of the call and pluses or minuses of using the app?

Despite the patient's negative outcome, from a battalion chief perspective, the incident ran very smoothly. It was an ease of mind to have worked with Handtevy during the testing phase to have a sure knowledge that the dosing recommended was correct. It was very convenient to be able to give a dose in volume to a team member in charge of medications and have that documented after administration. The metronome feature was nice to aid the team members doing CPR.

Overall impression of the tool:

This was the first call where I personally used the app on or witnessed a provider use the app. I find the usability of the app convenient and easy.

Did your crew members feel more comfortable using this app while running a pediatric code?
The entire crew was more comfortable and confident with the aid of Handtevy. After customizing the program to your individual protocol and operating guidelines it should allow all personnel to feel more comfortable.

Tips for other users:

My recommendation to others and myself would be to use this tool in the ACLS, BLS, or medical training consistently. I would also recommend (for the skeptic) to use their protocol to fact check and reverse equate what Handtevy recommends to put your mind at ease. It can be an accurate and assuring tool in a moment of need. American Fork Fire and Rescue (AFFR) highly recommends the use of this tool.

Regards,

Eddie Hales | Battalion Chief

American Fork, UT

Thank you to Chief Hales and Utah County PECC Kris Shields for pulling together this narrative!

Summary of Findings (data available as of 9/30/21) :

Cumulative Number of Child COVID-19 Cases*

• 5,899,148 total child COVID-19 cases reported, and children represented 16.2% (5,899,148/36,501,460) of all cases
• Overall rate: 7,838 cases per 100,000 children in the population

Cumulative Child COVID-19 Vaccinations:

As of September 29, 2021, the CDC recorded:

13.1 million US children younger than age 18 have received at least one dose of COVID-19 vaccine:

• Representing 56% of 12-17 year-olds

10.7 million of US children under age 18 are fully vaccinated:

• Representing 45% of 12-17 year-olds

Major new study finds COVID-19 vaccines are extremely effective

A national multi-center study conducted by researchers from Intermountain and other leading health systems across the country adds further evidence that COVID-19 vaccines are safe and highly effective at preventing severe illness.

Covid-19 Trackers

Johns Hopkins Global tracker (desktop)

Johns Hopkins Global tracker (mobile)

Utah Department of Health

Pediatric Education for the Prehospital Provider

Register online at www.peppsite.com. Look up classes in Utah and find the one that works for you. Once you find the class, go to jblearning.com, and look up pepp als in the search tool. Purchase the number ($18.95). Return to peppsite.org to register for the class and follow the prompts.

If you have any questions, please email Erik Andersen at erikandersen@utah.gov or text/call 435-597-7098. Continue to watch the website for additional classes.