Aug. 12, 2021
According to David Turay, M.D., Ph.D., a trauma surgeon at Mayo Clinic's campus in Rochester, Minnesota, "the concept of the golden hour takes a front row seat" in a penetrating trauma case in which a patient is shot or stabbed.
Although some medical professionals in trauma and emergency medicine counter that there is insufficient evidence that results for a patient involved in trauma fall off after precisely 60 minutes, the principle remains the same: Rapid intervention can make all the difference in patient morbidity and mortality. And in a 2015 editorial in Injury: International Journal of the Care of the Injured, Rogers and colleagues stated: "There is an aspect to trauma care that is very time dependent."
Penetrating trauma and its context
"Across the nation, penetrating traumas comprise 12% to 18% of all traumas," says Dr. Turay. "Though Mayo Clinic's patient volume with penetrating trauma — high projectile or stab wounds — is lower than other U.S. regions, it still occurs." From January through May 2021, 12% of Mayo Clinic's most serious trauma cases involved penetrating head, neck, torso, axilla or groin injuries. For example, in early summer 2021 in downtown Rochester, a shooting occurred with major injury.
When considering penetrating trauma, it's important to distinguish type, says Dr. Turay, who previously served as trauma surgery division chief at Loma Linda University Health, which received many of the people injured in the 2015 San Bernardino, California, mass shooting. Penetrating trauma includes high- and low-velocity events, either voluntary or involuntary. Dr. Turay says these categories are important from a public health perspective to develop prevention strategies.
High-velocity penetrating traumas using high-caliber weapons — gunshot wounds — are significantly more prevalent in the U.S. than in other countries, says Dr. Turay. He treated a patient in the ICU who had seven gunshot wounds. However, the injuries appeared survivable since they came from a low-caliber gun. He notes high-caliber guns leave behind a trail of destruction.
Tips on managing penetrating trauma
Dr. Turay offers these insights for professionals dealing with penetrating trauma:
Although CPR is a common tool, especially in the field, if the person doesn't have a pulse after penetrating trauma, CPR is not helpful. Unlike a heart attack or a choking incident, the heartbeat's cessation is due to blood loss, rendering this resuscitative method ineffective.
"It would be like having a leaky hose or massaging a half-empty tank," Dr. Turay says. He also notes that interventions can be high risk for providers and that health care professionals are resource custodians. Thus, if a patient has been down for 20 minutes or more, consider whether interventions are an appropriate risk.
ABCs of trauma
It's critical with penetrating trauma to keep a systematic approach with the trauma ABCs:
- Get an airway established, ensuring there's no oxygen flow impediment. This is usually an endotracheal tube, when feasible.
- Place chest tubes for hemothorax or pneumothorax.
- Check the circulatory system, prioritizing bleeding control, and determine IV access.
- Quickly initiate intravascular volume repletion, ideally blood transfusion in patients with clinical signs of shock.
- Be sure to expose and look in the axillae and groin as well as turning the patient. Mark wounds with paper clips prior to X-ray.
Dr. Turay says that anxiety during IV insertion in high-stakes scenarios is normal. He encourages trauma providers to sharpen IV access skills, remembering that the intraosseous route is equally effective and relatively easier to attain in patients with profound shock.
The professional's eyes and imagination are key to penetrating trauma diagnosis, determining missile or penetrating object trajectory and intracavitary bleeding presence. Paper clips at the puncture site aid in matching up possible organ involvement on plain films. When available, a focused assessment with sonography in trauma (FAST) scan is an invaluable adjunct. Mapping the path of the bullet or knife and, by inference, the injured organs, forms the basis for timing and type of intervention.
When caring for a patient who's experienced penetrating trauma, hemorrhage control, either externally by applying pressure or tourniquet, or surgical control is the next order of business after controlling the patient's air and ensuring adequate oxygen delivery. This is often the case even when a concomitant devastating neurological injury is present.
Dr. Turay says he likes to bear in mind, "First control the bleeding, and then assess the rest. As long as the patient has a heartbeat and blood pressure, you need to focus on bleeding control." He encourages all trauma personnel to take the Stop the Bleed course.
Dr. Turay recommends not touching or removing an impaled object, as it could worsen the injury. Also, he explains it's impossible to know what the object may touch inside the patient's body, perhaps compressing a vessel enough to prevent bleeding out. He suggests waiting for a surgeon to address it, as interference may worsen the injury. Trauma professionals may help the patient, however, with wound packing or a tourniquet for hemorrhage control.
Along with hemorrhage control, a patient who's experienced penetrating trauma needs immediate blood transfusion. Data suggest timely blood administration in a balanced ratio makes a difference, indicates Dr. Turay.
Having universal donor, or O-negative, blood at all times may be the difference between life and death. Starting with crystalloid is acceptable, but Dr. Turay suggests moving quickly to blood. "Instead of lots of crystalloids, stop at liter No. 1 and go to blood," he says. "Otherwise, you'll dilute the remaining blood-clotting factors the patient has and render the patient hypothermic, setting back your bleeding control efforts."
Dr. Turay emphasizes that a portable FAST scan is essential for people with penetrating trauma injuries. This scan is a specialized ultrasound designed to look into cavities where blood is most likely to accumulate, such as:
- Around the heart and both pleural cavities
- Between the right kidney and liver: Morison's pouch, in the right upper quadrant
- Between the spleen and left kidney: the splenorenal recess, in the left upper quadrant
- Around the bladder
Dr. Turay also suggests using the same ultrasound technology to assess for lung sliding — lung collapse (pneumothorax) — with an extended focused assessment with sonography for trauma (eFAST).
A FAST scan device in experienced hands could have sensitivities upward of 90%, he says, calling ultrasound technology with eFAST along with plain radiography the most basic and indispensable trauma center tools, especially in rural settings. CT scans, when available, could provide more-detailed evaluation of the patient's injuries but also could be time-consuming and inadvisable for a patient in hemorrhagic shock. A positive FAST scan in the patient with penetrating trauma who's in shock is sufficient information to warrant emergent surgical exploration.
Dr. Turay urges trauma centers at any designation level to have ultrasound, or specifically an eFAST scan device, available and trained personnel to use it. He notes that all Mayo Clinic emergency medicine and general surgery residents become proficient in performing a FAST scan as they mature in their training.
Because of the potential for complex injuries that require a multidisciplinary provider team, patients with penetrating trauma injuries often are best cared for at a higher level trauma center — a Level 1 or Level 2 Trauma Center. The role of smaller and sometimes rural receiving facilities, nonetheless, remains crucial in stabilizing the patient, initiating the work-up and facilitating prompt evacuation to a tertiary care center. Unstable patients with signs of ongoing noncompressive hemorrhage, or patients with bleeding into body cavities that is visible with a positive FAST scan, require providers to think and act quickly.
"Blood pressure drop in patients experiencing trauma signifies they are already in Class 3 — out of four — hemorrhagic shock, having lost an estimated 30% to 40% of their blood volume," says Dr. Turay. "Any delay will mean imminent cardiac arrest."
While emphasizing speed and getting the patient to the nearest trauma center rapidly, Dr. Turay also recognizes that resources and experience with penetrating trauma may vary among medical centers. "Do the best you can based on your training," says Dr. Turay.
For more information
Rogers, FB, et al. The golden hour in trauma: Dogma or medical folklore? Injury: International Journal of the Care of the Injured. 2015; 46:525.
Stop the Bleed. American College of Surgeons.