This case was originally written by Dr. Kyla Caners in 2015 and recently updated by Drs. Chris Heyd and Chad Singh.
Dr. Caners is a staff emergency physician and Assistant Professor at McMaster University in Hamilton, Ontario. She is an assistant director at McMaster’s Centre for Simulation-Based Learning, responsible for Patient Safety and In Situ Simulation. Dr. Heyd is a staff emergency physician and trauma team leader in Hamilton, Ontario and Simulation Director of McMaster University’s FRCP-EM program. Dr. Singh is a PGY-3 resident in Emergency Medicine at McMaster University with a special interest in trauma and simulation.
Why it Matters
From a clinical perspective, gun shot wounds can cause massive internal injuries that are not always apparent from a superficial examination of a patient. This case requires learners to use the tools common to all major trauma – a structured clinical exam (such as the ATLS primary survey), close attention to vital signs and GCS and bedside imaging or x-rays and ultrasound. Major trauma requires prompt treatment including massive transfusion, adjunct medications and arranging definitive surgical management.
From a simulation perspective, this case has been used for nearly seven years and was ready for a re-fresh. The basic goal is to give junior learners an opportunity to manage a critically injured patient in the safety of the sim lab. In the current form, emphasis has been placed on giving early blood products over crystalloid, as well as an opportunity to discuss interval developments in the literature (like blood product ratios in massive transfusion) and to take a close look at local protocols. Cases in any sim curriculum should undergo periodic review to ensure they are relevant and up to date.
Clinical Vignette
A 20-something year old unknown male is brought to your community ED in a wheelchair by friends. They were at a party and a fight broke out. It was loud and dark and then they saw the patient collapse. His low back is covered in blood. He is awake but moaning. Unknown identity/meds/allergies.
Case Summary
A 20- something year old male is dropped off at a community ED after a gunshot wound to the lower back. He will quickly be placed in a resuscitation bed and placed on monitors. His initial vitals will include tachycardia but no hypotension. The team will proceed through their primary survey and identify only one gunshot wound. If they do not recognize possible free fluid and the need for blood, the patient will become increasingly hypotensive. They will be required to intubate the patient while waiting for the staff surgeon to arrive in order for the patient to go to the OR.
Download the case here: Gun Shot Wound to Lower Back
EM Sim Cases 