المتخصصون في المجالات الطبية

Nov. 10, 2022

John M. Zietlow, M.D., a trauma and acute care surgeon at Mayo Clinic's campus in Rochester, Minnesota, grew up discussing traumatic incidents — minus identifying details, of course. These discussions happened at the dinner table with his dad, Scott P. Zietlow, M.D., a Mayo Clinic trauma surgeon, and his mom, a pediatrician. His parents did not allow playing hockey or football, or having foam dart guns or squirt guns in the house.

Today, however, following in his dad's footsteps, guns of all types and resulting penetrating trauma are part of Dr. Zietlow's repertoire as a trauma and acute care surgeon.

While he trained as a physician, Dr. Zietlow found that his interests kept returning to trauma, for its fast-paced and unknown clinical situations, quick fixes, and positive outcomes in difficult circumstances he saw in his father's career and in his own training.

Now, as a staff physician, Dr. Zietlow sees gun incidents as a problem in the United States and as a growing issue touching Mayo Clinic's trauma centers.

"It's an issue with large-scale shootings appearing to increase," he says. "Trauma is at the forefront of this."

Dr. Zietlow saw penetrating trauma in his surgical rotation at Creighton University School of Medicine and during his general surgery residency and surgical critical care fellowship at Mayo Clinic. He observes that in the 5 to 6 years he's been at the Rochester campus of Mayo Clinic, gun violence has become more prolific and has increased from what Mayo trauma has seen historically.

Penetrating trauma resuscitation procedure

Dr. Zietlow says that he sees managing patients with penetrating trauma as often requiring more invasive procedures in the trauma bay than other types of trauma. The goal with penetrating trauma is to quickly identify the trajectory of the ballistics, he explains. A methodical and organized approach is key to successful work-up and resuscitation of this injury.

"You can always miss injuries if you are not systematic and performing thorough primary and secondary surveys in the trauma bay," he says. "Thorough communication from surveyor to trauma surgeon and documenting nurse also are critical."

He recommends following the trauma ABCDEs with patients who've experienced penetrating trauma, indicating that focusing on these steps will help avoid missing life-threatening injuries and prevent morbidity and mortality from any overlooked injuries.

At each step of the ABCDEs, he recommends making a hard stop. If any abnormalities persist after that step, the trauma team must address them before proceeding with the remaining steps.

Although bleeding may be significant for a patient with this injury, he also says to be sure not to focus only on this issue, remembering that things happen simultaneously in the trauma bay.

The trauma lingo "strip and flip" refers to a quick method to assess any penetrating injuries on the posterior exam or hidden under clothing, looking over all bodily surfaces to locate any injuries. The team should follow this procedure. Trauma professionals also must determine the trajectory of any bullets involved in the injury to assist in surgical planning. They place and tape paper clips over the ballistic wounds and then obtain plain film imaging.

In the appropriate clinical situation, justification exists for an emergency department thoracotomy. However, contraindications to resuscitative thoracotomy in patients with penetrating injury include no signs of life at the scene of injury, prolonged lack of pulse for more than 15 minutes at any time, or massive, nonsurvivable injuries.

More-significant injuries with penetrating trauma, however, can cause a patient to bleed out faster than with blunt trauma, requiring massive transfusion protocol to replace blood volume. Dr. Zietlow suggests starting with a 1-1-1 ratio of packed red blood cells, platelets and fresh frozen plasma. Focus on replacing lost volume until receipt of lab results with the coagulation parameters, and then continue with coagulopathy-specific resuscitation.

Warmth also is critical for a patient following penetrating trauma to maintain core body temperature. Thus, provide the patient with warm blankets and warm any fluids administered.

Dr. Zietlow also explains that resuscitating a patient with penetrating trauma who is unknown to the trauma team can be challenging.

"Typically, the patient shows up in your trauma bay, and you don't know much about them, such as medical history, comorbidities or medications prescribed," he says.

He notes that the trauma team must determine if the patient takes anticoagulants or beta blockers, which require changes in the resuscitation protocol. Consequently, looking for a medical alert on the patient or for an ID in the patient's wallet, plus looking in the patient's medical record as soon as possible, becomes crucial to assist the patient with coagulation. If no ID exists, label the patient as unidentified. Rapid laboratory assessment of the patient's blood also is essential to determine any medications taken. If the lab results indicate the patient's clotting factors are abnormal, the trauma team must replace them.

If aware the patient will be in surgery next, the team should avoid aggressively administering fluid to prevent increased blood pressure. That is, if the patient is not severely hypotensive with a systolic blood pressure around the 80 mm Hg range.

Predictors of poor outcomes for penetrating trauma

Dr. Zietlow warns trauma professionals about the lethal triad that may occur without well-executed resuscitation: hypothermia, coagulopathy and acidosis. He indicates that a primary responsibility of the trauma team treating a patient with a penetrating trauma is recognition of the shock state and early and aggressive interventions to prevent these three conditions from occurring. Or it will lead to worse outcomes. This involves the use of blood rather than fluid, to "refill the tank," as Dr. Zietlow says.

Other factors that may contribute to worse outcomes for a patient with this injury include:

• Longer transport time with active bleeding.
• Greater number of penetrating injuries.
• Lower patient physiologic reserve, often influenced by considerations such as diabetes, obesity, hypertension and older age.

Factors for transferring or keeping the patient at your hospital

Dr. Zietlow recommends making transfer decisions on a case-by-case basis for patients who have suffered penetrating trauma. The Advanced Trauma Life Support principle is to avoid delaying transfer. He suggests considering the following as you determine if it's appropriate to transfer a patient to a higher level trauma center:

• Distance. Especially if the transfer involves a short distance to definitive care, request patient transport as soon as possible.
• Treatment resources. Consider whether your facility may have more resources for the patient than a ground ambulance.
• Blood accessibility. Look at whether the say Mayo Clinic Ambulance Service's air ambulance may have more available blood for the patient than your hospital.
• Air ambulance availability. If weather conditions are adverse, or the helicopter is not currently available, send essential equipment in the ground ambulance with the patient. This may mean that Mayo emergency medical services personnel will work to stabilize the patient at your facility and then place a chest tube and provide appropriate blood products in the ambulance.

"Each clinical situation can be so different, and it's a fine line to decide if you will transfer a patient with penetrating trauma or not," Dr. Zietlow says. "If you plan to transfer, I suggest communicating early with the receiving facility, and preparing your patient for the transit with ongoing resuscitation needs."

For more information

Refer a patient to Mayo Clinic.