Bullets and Ballistics

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• To Provide a brief Knowledge of the different types of firearms and

•To Present the type and extent of wounds that may be expected in
UK Prehospital Care

• Review the principle between permanent and temporary cavitation

•To impart practical advice for the Prehospital practitioner in dealing
with firearm injuries and provide some “ Pearls and Pitfalls ”
• In 2009/10 there were 40 fatal injuries caused by the use of a firearm and 405 serious
injuries. All of the 40 fatalities in 2009/10 involved a weapon being fired, with 28 of the
fatalities involving the use of a handgun and 7 involving the use of a shotgun

•Hand guns were fired in only 10% of offences but if they were fired 30% of these
offences resulted in a fatal or serious injury, compared with 6% for all other weapon

• Firearm offences involving any type of injury increased by 5 percent from 3615 in
2008/09 to 3,641 in 2009/10

• One police officer was seriously injured and a further 16 slightly injured by firearms
whilst on duty in 2009/10. This is comparable with an average of 16 per year.

Homicides, Firearm Offences and Intimate Violence 2009/10: Supplementary Volume 2 to Crime in England and Wales
Firearms used by CO19. H & K snipers rifle.
       MP5A. Glock 19 Auto pistol.
        Firearms used by naughty people.
Mac10                Uzi
                       Naughty people guns cont… Rifles
AK47                                       Car 15 (Version of the M16)
Mikhail Kalashnikov                        Designed 1967
Avtomat Kalashnikova
Designed 1947
There are thousands of variants when it comes to bullets…….
                        Some Physics….
Principia Matematica 1759 Sir Issac Newton E =M x V
Willem Gravesande & Émilie du Châtelet       E = M x V²
Kinetic Energy = ½ M x V²
M16 bullet weighs 55gms but travels at 3200ft/sec .45 calibre bullet weighs 230gms but travels at
810ft/sec. M16 bullet is roughly 1/5th the weight but produces FOUR times the energy. (1280ft/lb
versus 335ft/lb) this is down to speed.
.32 Cal Subsonic
9mm Supersonic speed
HV 5.52cal Supersonic 2800ft/sec
               Subsonic                                                              Supersonic

If the sum of the diameter of the entrance and exit wounds (if present) at their widest
points is less than 10cm this is likely to be a low energy transfer wound. If the sum is
greater than 10cm or 2 fingers can easily be introduced into either wound the wound is
likely to be high energy transfer.
Driscoll P, Skinner D, Earlam R.(2000) ABC of Major Trauma. 3ed Ed. London. Pg 152
                    Temporary Cavity
A High Energy round can produce 100x atmospheric pressure as it
passes through tissue!! This gelatine block illustrates a HE round
entering from the right and the temporary cavitation it causes.
      Wound Profiles
Wound Profile a HE round (non-fragmenting)
                   Wound Profiles cont…
Wound profile of a 9m.m round. Note how much more stable the round is
   Wound Profiles Cont….
Wound Profile of a HE fragmenting round
                             Wound profiles Cont…
Wound profile produced by a 7.62 full metal jacket bullet (from a AK-47) It
does not deform in tissue and travels 26cm before it begins to yaw. This
entrance wound can resemble a much lower velocity handgun wound.
       Take Home Message

  Treat the injury not the
alleged weapon or ballistic
characteristics. Use caution
when describing wounds as
      exit or entrance
Abdominal visceral Injury occurs in 80-90% of bullet wounds but only 30% of stab wounds, however a
⅓ of abdominal stab wounds with serious visceral injury at operation have minimal physical signs.
Driscoll P, Skinner D, Earlam R.(2000) ABC of Major Trauma. 3ed Ed. London. Pg 56
      Take Home Message

Don’t Assume Bullets Take
    Linear Pathways
       Take Home Message
Some Bullet Wounds are not
 Some look more superficial
       than they are!
Shotgun cartridge just after leaving the barrel.       At 2 meters. The dark object behind the ‘Shot’ is
                                                       the wad. If fired from close range this can also
                                                       cause injury

       Most serious human wounds occur within 18yards ( 17 meters) from the point of firing
                         DeMuth WE:The mechanism of gunshot wounds, J Trauma 11:219,1971.
Explosive Gases will also damage tissue at close range
Shotgun Pellets are round and so will lose speed and stability
 rapidly. Be prepared to search more laterally for pellets
                               Patterns of Shotgun Injury
Type               Wound appearance                        Injury                              Mortality
Contact                                              Widespread tissue                         85% - 90%

Close                                                Penetrated beyond                         15% - 20%
                                                        deep fascia

Intermediate                                          Penetrates SQ tissue                        0 - 5%
                                                       and deep fascia

Long Range                                                Superficial skin                          0%

Modified from Sherman RT, Parish RA: Management of shotgun injuries: a review of cases, J Trauma 18:236,1978
        Take home message
Close range shotgun wounds
  are devastating. Assume
  major structural damage
until proven otherwise. Look
  more laterally to impact
      point than normal.
                    On Approach
                            The 6 P’s
       Prior Planning and Preparation Prevents Poor
Running Call:
RVP RVP RVP RVP where are the police meeting???…..,
Duty Officer, Availability of HEMS/Air Ambulance/BASICS,
Local Resus Capacity, Cardiothoracic/Neuro Capability?
Special considerations CBRN/SORT
                             Safety at Scene
Appropriate PPE should
be used, when available, but
this does not mean that you
can then work in the inner
cordon. There is no role for the
NHS in the inner cordon.
“She was saved from serious injury because
one shot was stopped by her stab-proof vest
and the other grazed her shoulder. Mrs
 O'Rourke said she was attacked as she walked
 back to her fast-response car after treating a
patient in King's Close, Leyton, at 3.30am on
23 August 2009.”
                                 Behind Armour Blunt Trauma BABT
1969 Vietnam 1st case report of lethal BABT US sergeant hit by M16 bullet – died in 45 minutes due
to massive pulmonary contusion.

Reported in 1970´s by Caroll and Soderstrom case series of Police wearing kevlar soft armour hit by
handgun bullets. All survived with no significant cardiorespiratory sequale.

1995 Aid worker hit by 14.5mm bullet – skin & muscle damage Cx no # ribs small haemothorax =
chestdrain. Later Cx in day showed developing pulmonary contusion – uneventful recovery.

Largely assosiated with the defeat of low energy bullets and flexible textile armour systems.

UK police 5 threatgroups of armour
Maximum back-face deformation is 44 millimeters for low risk patrolling duties

Maximum back-face deformation is 25 millimeters for severe threat group

Keep in mind even if there is the absence of a defect on the skin
Mahoney PF, Ryan J, Brooks A, Schwab CW.(2005) Ballistic trauma: A practical guide. 2nd Ed.
Initial Assessment
                                                        <C> ABC
                             Catastrophic Haemorrhage
                               Battlefield Advanced Trauma Life Support (BATLS)
   “Inner-city gunshot wounds and increasingly prevalent knife injuries are likely to present civilian Prehospital and
 hospital personnel with casualties who may benefit from current military haemorrhage protocols or adaptations of
    these. The parallels illustrate the need for civilian medical, nursing and paramedical personnel to be aware of
innovations and developments in the military environment, where change is accelerated by the military imperative to
     improve combat casualty outcomes , and to adopt practices, where appropriate, to the benefit of the NHS”

T.J. Hodgetts, P.F. Mahoney. M.Q. Russell, M. Byers ABC to <C>ABC: redefining the military trauma paradigm. EMJ 2006;23:745-746
                                  Compressible V Non Compressible
                            Direct Pressure of the wound ± elevation of the limb

                                                     Wound packing

                                                 Windlass technique*

                                                    Indirect Pressure

                                                   Use of tourniquet

                                ± Use of topical haemostatic agents at any time

*The windlass technique involves application of a dressing directly over the wound, held in place by a broad bandage (or crepe
bandage) secured with a not over the wound. A pen or a similar object is placed under the knot and rotated until tight and then
                       secured in place, thus providing a sustained significant force of direct pressure.

          C.Lee, K.M. Porter, T.J. Hodgetts. Tourniquet use in the civilian Prehospital setting. EMJ. 2007;24:584-587
                                              Tourniquets                          Negatives
•Majority of external haemorrhage can be controlled by direct pressure
• Inappropriate use – in a recent paper by Lakstein (2003) on military
tourniquet use, 47% of 110 tourniquet applications were not clinically
• Preventing arterial blood flow to a limb will result in ischemia. Continuous application for > 2hours
can result in permanent nerve injury, muscle injury, vascular injury and skin necrosis.
• Reperfusion injury may also result from tourniquet use.
•Incorrectly applied in non amputated limbs there may be a mismatch between occlusion of the
lower pressure venous outflow and inadequate occlusion of arterial blood flow. Therefore increasing
distal bleeding.
• Applied to a hypotensive patient pre resuscitation, haemorrhage may stop. However when
resuscitated to a higher systolic the bleeding may restart.
•A properly applied tourniquet is painful and this has led to inadequate tightening or inappropriate
Prehospital removal.
• In Lakstein’s study (2003) they identified that 5.5% of 110 Prehospital tourniquet applications
resulted in neurological complications, with an ischemic time between 109-187 minutes. None of
these resulted in limb loss. The mean use of a tourniquet with no complications was 78 minutes.

C.Lee, K.M. Porter, T.J. Hodgetts. Tourniquet use in the civilian Prehospital setting. EMJ. 2007;24:584-587
                                           Tourniquets                        why then?
Analysis of data from the Vietnam war found that 7% of deaths potentially

US SF (2001-2004) in the Global War on Terrorism 13% deaths potentially
 Unpublished from this data 18 casualties from 35 (51%) who died from isolated extremity injury
could have potentially been avoidable²

In a 4 year period of tourniquet use by the IDF Lankstein reported that there were no deaths from
uncontrolled limb haemorrhage among 550 injured patients.³

¹Bellamy RF. The causes of death in conventional land warfare: implications for combat casualty care research. Mil
Med. 1984;149:55-62
² Holcomb JB, McMullin NR, Pearse L, et al. Causes of death in US Special Operations Forces in the global war on
terrorism:2001-2004. Ann Surg. 2007; 245:986-991
³Lakstein D, Blumenfeld A, Sokolov T et al. Tourniquets for hemorrhage control on the battlefield: a 4-year
accumulated experience. J Trauma 2003; 54 (5suppl):S221-S225)
                                        Tourniquets Cont....
Recommended for stepwise approach or immediate application if…

• Extreme life threatening limb haemorrhage or limb amputation so that
A & B can be treated and <C> then reassesed
• Life threatening limb haemorrhage not controlled by simple methods
•Point of significant haemorrhage from limb is not peripherally accessible due to entrapment
•MCI with extremity haemorrhage and lack of resources to maintain simple methods of haemorrhage

If transit time to hospital is under 1 Hour the tourniquet should remain insitu until the patient is in the
operating theatre
C.Lee, K.M. Porter, T.J. Hodgetts. Tourniquet use in the civilian Prehospital setting. EMJ. 2007;24:584-587

Write on tourniquet/PCR/forehead… time of application. In a review of Operation Iraqi Freedom 39%
of casualties who had prehospital tourniquets applied did not have time of application.

Beekley AC et al. Prehospital Tourniquet use in Operation Iraqi Freedom:Effect on Hemorrhage control and outcomes. J
Trauma 2008;64:S28-S37
                                 Haemostatic dressings/agents

Analysis of autopsy data from American casualties sustained in Iraq and Afghanistan has shown that
over 80%of casualties with potentially survivable wounds – died from haemorrhage. Of these
aproximatly 20% died from wounds in the neck, axilla and groin.

Kelly JF, Ritenour AE, McLaughlin DF et al. Injury severity and causes of death from Operation Iraqi Freedom and
Operation Enduring Freedom: 2003-2004 versus 2006.J Trauma. 2008;64:S21-S27
             The esssential end reactions of the clotting process

                  Prothrombin activator
                     Calcium ions (IV)

Prothrombin                                                  Thrombin

                       Fibrinogen (I)                                            Fibrin

Action                                              Transformation
Adapted from Hinchcliff S. et al 1999. Phyhsiology for nursing practise 2nd Ed
                                              QuikClot ®
Works by absorbing the water component of blood in an exothermic reaction,
thereby concentrating clotting factors, it also supplies Ca²+ ions and activates
platlets as further adjuncts to coagulation.

A complex groin injury with transection of the femoral vessels and 3 minutes of uncontrolled hemorrhage was created
in 30 swine. Mortality was 83% without treatment, 33.4% with standard gauze and 0% with Quikclot.¹

Case review of 103 patients overall efficacy rate of 92%, 3 cases of burns²

¹Alam HB, Uy GB, Miller D et al. Comparative analysis of hemostatic agents in a swine
model of lethal groin injury . J Trauma. 2003;54: 1077-1082
²Rhee P, Brown C, Martin M et al. QuickClot use in trauma for hemorrhage control case
series of 103 documented uses. J Trauma. 2008;64:1093-1099
Is a chitosan based dressing which has been noted to have an effect on
haemostasis due to direct adherance to the wound, it may also aid in the
recruitment of red blood cells and platelets, this process then forms a pseudo

A complex groin injury with transection of the femoral vessels and 3 minutes of uncontrolled hemorrhage was created
in 48 swine. The animals were then randomized to four treatment groups (12 animals each).

Celox reduced rebleeding to 0% (p < 0.001), HemCon to 33% (95% CI = 19.7% to 46.3%, p = 0.038), and QuickClot to
8% (95% CI = 3.3% to 15.7%, p = 0.001), compared to 83% (95% CI = 72.4% to 93.6%) for SD. CX improved survival to
100% compared to SD at 50% (95% CI = 35.9% to 64.2%, p = 0.018). Survival for HC (67%) (95% CI = 53.7% to 80.3%)
and QC (92%; 95% CI = 84.3% to 99.7%) did not differ from SD.

In use with DMS & HEMS

Kozen BG, Kircher SJ, Henao J et al An alternative hemostatic dressing: comparison of CELOX, HemCon, and QuikClot.
Acad Emerg Med. 2008 Jan;15(1):74-81.
                                    Prehospital Haemostatic dressings a
                                            systematic review

From 60 articles collated, 6 clinical papers and 37 preclinical animal trials were
eligible for inclusion in this review. Products have been tested in three
different types of haemorrhage model: low pressure, high volume venous
bleeding, high pressure arterial bleeding and mixed arterial-venous bleeding.
The efficacy of products varies with the model adopted. Criteria for the 'ideal
battlefield haemostatic dressing' have previously been defined by Pusateri, but
no product has yet attained such status. Since 2004, HemCon (a mucoadhesive
agent) and QuikClot (a factor concentrator) have been widely deployed by
United States and United Kingdom Armed Forces; retrospective clinical data
supports their efficacy. However, in some recent animal models of lethal
haemorrhage, WoundStat (mucoadhesive), Celox (mucoadhesive) and
CombatGauze (procoagulant supplementor) have all outperformed both
HemCon and QuikClot products.

Granville-Chapman J, Jacobs N, Midwinter MJ. Pre-hospital Haemostatic dressings: A Systematic Review. Injury.
2010.Oct 27

OP     Airway Manouvers   NP

iGel                             LMA

ET                         RSI
90 casualties sustained a penetrating neck injury. MOI = explosion in 66 (73%) and from GSW in 24 (27%). Cervical
spine injuries (either cervical spine fracture or cervical spinal cord injury) were present in 20 of the 90 (22%)
casualties, but only 6 of these (7%) actually survived to reach hospital. Four of this six subsequently died from injuries
within 72 h. Only 1 (1.8%) 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. Penetrating ballistic trauma
to the neck is associated with a high mortality rate. Our data suggests 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 (e.g. shooting
incidents or terrorist bombings), the risk/benefit ratio of mandatory spinal immobilisation is unfavourable and may
place medical teams at prolonged risk. In addition cervical collars may hide potential life-threatening conditions.¹

In total, 45,284 penetrating trauma patients were studied; 4.3% of whom underwent spine immobilization. Overall
mortality was 8.1%. Unadjusted mortality was twice as high in spine-immobilized patients (14.7% vs. 7.2%, p < 0.001).
The odds ratio of death for spine-immobilized patients was 2.06 (95% CI: 1.35-3.13) compared with nonimmobilized
patients. Prehospital spine immobilization is associated with higher mortality in penetrating trauma and should not be
routinely used in every patient with penetrating trauma.²

The current literature suggests that prehospital cervical immobilisation may not be necessary unless the patient has
focal neurological deficits. ³

¹HauteER, Kalish BT, Efron DT et al. Spine immobilization in penetrating trauma: more harm than good? J Trauma. 2010 Jan;68(1):115-20
²Ramasamy A, Midwinter M, Mahoney P, Learning the lessons from conflict: pre-hospital cervical spine stabilisation following ballistic neck
trauma. Injury. 2009 Dec;40(12):1342-5
³Brywczynski JJ, Barrett TW, Lyon JA et al. Management of penetrating neck injury in the emergency department: a structured literature
review. Emerg Med J. 2008 Nov;25(11):711-5
             Breathing 100% O2
Feel             Trachea
Look             Wounds to neck
Auscultate       Emphysema
Percuss          Larynx #
 (Sa02)          Expose
Tension pneumothorax
Open pneumothorax
Massive haemothorax
Flail chest                   (pain releif)

Cardiac tamponade                                          (20ml removal 25% aspiration not possible)

Driscoll P, Skinner D, Earlam R.(2000) ABC of Major Trauma. 3ed Ed. London. Pg21
                                   Tension Pneumothorax
Universal findings
•Chest Pain
•Respiratory distress

Common findings (50%-75%)
• Tachycardia
• Ipsilateral decreased air entry

Inconsistent findings (< 25% of cases)
•Low SpO2
• Tracheal deviation
• Hypotension

Rare Findings (about 10%)
• Cyanosis, Ipsilateral chest hyper expansion or mobility
• Hyperresonance, Sternal resonance /
• Decreasing LOC , Acute epigastric pain / cardiac apical displacement
S Leigh-Smith, Harris T. Tension Pneumothorax – time for a rethink?. Emerg Med J 2005;22:8-16.
                                 Needle Chest Decompression

Up to 40% failure rate in some studies – Standard 14g cannula not long enough for up
to 35.4% of women and 19.3% men¹

Paramedic misdiagnosis (only 4/19) in one study²

18 of 37 cases underwent chest decompression (17 thoracostomy, 1 needle
decompression). Four patients had a return of cardiac output (3 tension pneumothorax,
1 bilateral pneumothorax). Six further cases were positive for intrathoracic injury. In 2
cases the injuries identified were incompatible with life and resuscitation efforts were
consequently ceased³

¹Mistry N, Bleetman A, Roberts KJ. Chest decompression during the resuscitation of patients in prehospital traumatic
cardiac arrest. Emerg Med J. 2009 Oct;26(10):738-40
²S Leigh-Smith, Harris T. Tension Pneumothorax – time for a rethink?. Emerg Med J 2005;22:8-16.
³Zengerink I, Brink PR, Laupland KB, Needle thoracostomy in the treatment of a tension pneumothorax in trauma
patients: what size needle? J Trauma. 2008 Jan;64(1):111-4
                                Open Pneumothorax
The Bolin and Asherman chest seals were equivalent in preventing the
development of a tension pneumothorax in this open pneumothorax model.
However, the Bolin chest seal demonstrated stronger adherence in blood
soiled conditions

             Bolin                                                          Asherman

Arnaud F, Tomori T, Teranishi K, Evaluation of chest seal performance in a swine model: comparison of Asherman vs.
Bolin seal. Injury. 2008 Sep;39(9):1082-8
Pulse Check Distal First/ Rate/ Rhythm

       Skin temp/ appearance

              Cap Refil

                                            Circulation Access
X 1 and if possible X2 14g IV Access in ACF but en route!!!

From October 1985 through November 1986 we prospectively studied IV access attempts in 350 consecutive patients.
Overall IV's started at the scene were 77% successful (n = 70) and en route 81% (n = 213) of attempts were successful.
Of those with BP less than 100 mm Hg, there were 66% successful on-scene attempts and 72% successful en-route
attempts. Protocols for IV administration in non-trapped patients should initiate IV access only en route to the hospital
while the ambulance is moving. Even if delay at the scene is minimal, it is not possible to justify any delay, since IV's
can be successfully instituted en route.

O'Gorman M, Trabulsy P, Pilcher DB. Zero-time prehospital i.v. J Trauma. 1989 Jan;29(1):84-6
                                               IO Access
EZ-IO Fast & effective (97% effective function in combat casualties)

Simple technique


Cooper BR, Mahoney PF, Hodgetts TJ, Intra-osseous access (EZ-IO) for resuscitation: UK military combat experience.
J R Army Med Corps. 2007 Dec;153(4):314-6

A total of 776,734 patients were studied. Approximately half (49.3%) received prehospital IV. Overall mortality was
4.6%. Unadjusted mortality was significantly higher in patients receiving prehospital IV fluids (4.8% vs. 4.5%, P <
0.001). Multivariable analysis demonstrated that patients receiving IV fluids were significantly more likely to die (odds
ratio [OR] 1.11, 95% confidence interval [CI] 1.05-1.17). The association was identified in nearly all subsets of trauma
patients. It is especially marked in patients with penetrating mechanism (OR 1.25, 95% CI 1.08-1.45), hypotension (OR
1.44, 95% CI 1.29-1.59), severe head injury (OR 1.34, 95% CI 1.17-1.54), and patients undergoing immediate surgery
(OR 1.35, 95% CI 1.22-1.50).
CONCLUSIONS: The harm associated with prehospital IV fluid administration is significant for victims of trauma. The
routine use of prehospital IV fluid administration for all trauma patients should be discouraged.

Haut ER, Kalish BT, Cotton BA et al. Prehospital Intravenous Fluid Administration is Associated With Higher Mortality in
Trauma Patients: A National Trauma Data Bank Analysis. Ann Surg. 2010 Dec
Crysrtalloids to be used

• Penetrating injury boluses of 250mls to acheive verbal contact which is taken to indicate CNS
perfusion adequacy.
• In a patient where this endpoint is not possible SBP of 80mmhg is used
• haemodynamically unstable = code red to hopsital¹

• Fluid rates 14g = 1tr/3min, 16g = 1tr/6min, 18g = 1tr/20min
• Fluid at room temeperature will cause approx ↓1ºC per Litre²

• Fluids should be warmed to 39°C prior to infusion³

¹HEMS SOPs June 2008
²BASICS monograph on Fluids
³ PHTLS 6th ED
Is a defect in the body's mechanism for blood clotting, causing susceptibility to bleeding
The underlying mechanism ↑ anticoagulant Protein C pathway which ↓factors V &VIII

Up to 25% of trauma patients in some series have Acute Traumatic Coagulapathy,
identified 20 min post injury and may be earlier

• Hypothermia is a driver – keep them warm
• Haemodilution is a driver – adhere to hypotensive resuscitation
• Acidemia is a driver – Oxygenate
                                                          CRASH 2
BACKGROUND: Tranexamic acid can reduce bleeding in patients undergoing elective surgery. We assessed the effects
of early administration of a short course of tranexamic acid on death, vascular occlusive events, and the receipt of
blood transfusion in trauma patients.
METHODS: This randomised controlled trial was undertaken in 274 hospitals in 40 countries. 20 211 adult trauma
patients with, or at risk of, significant bleeding were randomly assigned within 8 h of injury to either tranexamic acid
(loading dose 1 g over 10 min then infusion of 1 g over 8 h) or matching placebo. Randomisation was balanced by
centre, with an allocation sequence based on a block size of eight, generated with a computer random number
generator. Both participants and study staff (site investigators and trial coordinating centre staff) were masked to
treatment allocation. The primary outcome was death in hospital within 4 weeks of injury, and was described with the
following categories: bleeding, vascular occlusion (myocardial infarction, stroke and pulmonary embolism), multiorgan
failure, head injury, and other. All analyses were by intention to treat. This study is registered as ISRCTN86750102,
Clinicaltrials.govNCT00375258, and South African Clinical Trial RegisterDOH-27-0607-1919.
FINDINGS: 10 096 patients were allocated to tranexamic acid and 10 115 to placebo, of whom 10 060 and 10 067,
respectively, were analysed. All-cause mortality was significantly reduced with tranexamic acid (1463 [14.5%]
tranexamic acid group vs 1613 [16.0%] placebo group; relative risk 0.91, 95% CI 0.85-0.97; p=0.0035). The risk of
death due to bleeding was significantly reduced (489 [4.9%] vs 574 [5.7%]; relative risk 0.85, 95% CI 0.76-0.96;
INTERPRETATION: Tranexamic acid safely reduced the risk of death in bleeding trauma patients in this study. On the
basis of these results, tranexamic acid should be considered for use in bleeding trauma patients.

Shakur H, Roberts I, Bautista R, Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with
significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial. Lancet. 2010 Jul 3;376(9734):23-32
                                           Diesel/ GLF

         Time on Scene can Kill
                                           (Also applies to in A&E)

Outcome was worse in a group of 4856 patients brought to hospital by
Paramedics than in 926 patients brought in by bystanders, relatives
And police.

Demetriades D, Chan L, Cornwell E et al. Paramedic Vs Private transportation
of trauma patients. Effect on outcome. Arch Surg. 1996; 131:133-8
                       Trauma Divert
• Major trauma patients managed initialy in local hospitals have been
shown to be 1.5 to 5 times more likly to die than patients transported
directly to trauma centres

•There is an average delay of 6 hours in transfering patients from a
local hospital to a specialist centre. Delays of 12 or more hours are not
uncommon. Across the UK, almost all ambulance bypasses can be
acheived < 30 mins

Lord Darzi 2008
                                           Links · PDF file
                                                   Going Slow

Hydrogen Sulfide Sprague-Dawley rats were subjected to controlled hemorrhage to remove 60% of total blood.
Hydrogen sulfide was administered to rats either via airway as gas, or intravenous infusion as liquid. Outcome was assayed by survival.
Results: Using inhaled hydrogen sulfide gas, 75% of treated and 23% of untreated rats survived longer than 24 hours. Using
intravenous administered sulfide, 67% of treated and 14% of untreated rats survived longer than 24 hours. Morrison M, Blackwood J,
Lockett S. Surviving Blood Loss Using Hydrogen Sulfide Journal of Trauma-Injury Infection & Critical Care: July 2008, 65 ;1 :183-188

Dr Hassan Boston Trauma Unit 10ºC hypothermic resucitation –
thorocotomy ice cooling ? 90% survival

Cell death -reintro O2 Mitochondria is controller of death – Profesor

Zenon gas (neuroprotective) neonates - TBI

Thromboelastrometry (TEM)

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