The UK General Medical Council provides guidance on the reporting to police of gun and knife wounds.
The guidance describes a two-stage process:
You should inform the police quickly whenever a person arrives with a gunshot wound or an injury from an attack with a knife, blade or other sharp instrument. This will enable the police to make an assessment of risk to the patient and others, and to gather statistical information about gun and knife crime in the area
You should make a professional judgement about whether disclosure of personal information about a patient, including their identity, is justified in the public interest.
37 patients with blunt traumatic cardiac arrest underwent attempted resuscitation by a HEMS crew over a four year period. Chest decompression was performed in 18 cases (17 thoracostomy, one needle decompression). The procedure revealed evidence of chest injury in 10 cases (pneumothorax, haemothorax, massive air leak) and resulted in return of circulation and survival to hospital in four cases. All four cases died of associated major head injury, although one became a heart beating organ donor. Only half of the cases found to have pneumothorax demonstrated clinical signs of one prior to chest decompression.
The authors state: ‘Relying on clinical signs of the thorax alone will not identify all patients with these injuries, and our data support extending the practice into all patients with a suitable mechanism of injury together with external evidence of chest injury.’ Chest decompression during the resuscitation of patients in prehospital traumatic cardiac arrest Emerg Med J. 2009 Oct;26(10):738-40
Success rates with the bone injection gun were 71% (10 out of 14) in children <16 years and 73% (19 out of 26) in adults. Less encouraging data than that seen with the EZ-IO device, and consistent with the experience of some other services. Prehospital Intraosseus Access With the Bone Injection Gun by a Helicopter-Transported Emergency Medical Team J Trauma. 2009 Jun;66(6):1739-41
British military physicians reported the outcomes of patients sustaining penetrating neck injury from the Iraq and Afghanistan conflicts. Three quarters were injured in explosions, one quarter from gunshots.
Of 90 patients, only 1 of the 56 survivors to reach a surgical facility sustained an unstable cervical spine injury that required surgical stabilisation. This patient later died as result of a co-existing head injury. The authors conclude that penetrating ballistic trauma to the neck is associated with a high mortality rate, and their data suggest that it is very unlikely that penetrating ballistic trauma to the neck will result in an unstable cervical spine in survivors. In a hazardous environment the risk/benefit ratio of mandatory spinal immobilisation is unfavourable and may place medical teams at prolonged risk, and cervical collars may hide potential life-threatening conditions. Learning the lessons from conflict: Pre-hospital cervical spine stabilisation following ballistic neck trauma Injury. 2009 Dec;40(12):1342-5
Patients admitted to a level 1 trauma centre with traumatic brain injury whose end-tidal CO2 was kept with the Brain Trauma Foundation recommended limits of 30-35 mmHg (3.9-4.6 kPa) had a lower mortality than those whose CO2 was outside this range. The group in which the target was not achieved had a greater injury severity, which may have contribute to the difficulty in optimising ETCO2. Prehospital Hypocapnia and Poor Outcome After Severe Traumatic Brain Injury J Trauma. 2009 Jun;66(6):1577-82
This short cut review in the Best Bets format attempted to answer the question: “is cervical spine protection always necessary following penetrating neck injury?”
From the available evidence they draw the following conclusions:
In stab wounds to the neck (with or without neurological deficit) an unstable spinal injury is very unlikely and c-spine immobilisation is not needed
In gunshot wounds the value of cspine immobilisation is limited: for gunshot wounds without neurological deficit no immobilisation is required, while in cases of gunshot wounds with neurological deficit, or where the diagnosis cannot be made (ie, altered mental status), a collar or sandbag is advised once ABCs are stable, with close observation and intermittent removal to inspect and reassess.
In the rare event of penetrating injury with combined blunt force trauma, a collar or sandbag is advised if possible, once ABCs are stable, with intermittent removal to reassess.
A retrospective review of 4204 patients sustaining gunshot wounds (GSW) to the head, neck or torso examined the incidence of spinal cord injury and bony spinal column injury required operative spinal intervention. None of the patients demonstrated spinal instability requiring operative intervention, and only 2/327 (0.6%) required any form of operative intervention for decompression. The authors concluded that spinal instability following GSW with spine injury is very rare, and that routine spinal imaging and immobilisation is unwarranted in examinable patients without symptoms consistent with spinal injury following GSW to the head, neck or torso. The role of routine spinal imaging and immobilisation in asymptomatic patients after gunshot wounds Injury. 2009 Aug;40(8):860-3
A review of burn first aid treatments highlights the paucity of evidence on which to make firm recommendations. The authors recommend using cold running tap water (between 2 and 15 degrees C) and to avoid ice or alternative therapies. The optimum duration of first aid application and the delay after the injury for which first aid can still be effective are two areas of research which need further exploration. A review of first aid treatments for burn injuries Burns. 2009 Sep;35(6):768-75
The Paralyzed Veterans of America produce a number of evidence-based guidelines for management of spinal cord injury and its complications that may be useful for the critical care doctor, downloadable from here.
The most relevant to frontline professionals is the Early Acute Management in Adults with Spinal Cord Injury: A Clinical Practice Guideline for Health-Care Professionals. A summary of the major recommendations from this document can be found here.
A systematic review of pre-hospital intubation for head injured patients failed to show evidence of benefit of tracheal intubation or invasive ventilation. The authors acknowledge the lack of methodological quality in the studies reviewed and the predominance of US paramedic-delivered intubations without the use of anaesthetic drugs. Pre-hospital tracheal intubation in patients with traumatic brain injury: systematic review of current evidence Br J Anaesth. 2009 Sep;103(3):371-86
