Issue 45 Gunshot Wound & First-Aid Kits: Everything You Need to Know to Build Your Own Sandy Hughes Deciding what to carry in a medical kit is highly dependent on anticipating the injuries and illnesses you may encounter in a given situation. It’s also dependent on the space available for your gear. After all, the space available when partaking in outdoor activities off the beaten path can be quite limited. You must eliminate unnecessary items so that you can carry other essentials. If you carry a gunshot trauma kit on your person or in a range bag, it’s even more essential that the contents remain compact and free of clutter from unnecessary items. In choosing components to use in my medical kits, I drew on my experience of over 16 years as a paramedic, seven years as an ER nurse, and five years in my current role as a nurse practitioner in the ER and in trauma surgery. I saw definite patterns of injury related to outdoor sports, including shooting sports, and thought about what someone with only basic first-aid knowledge could carry in order to temporarily treat these injuries until they could be evaluated and treated definitively by medical providers. As a shooter and outdoor enthusiast, there are two essential medical kits I’d choose to have with me at all times: a gunshot trauma kit containing the bare-bones essentials to treat catastrophic penetrating injuries, and an expanded Individual First Aid Kit. GUNSHOT TRAUMA KIT COMPONENTS It’s estimated that 40 percent of trauma-related deaths worldwide are due to bleeding and its consequences. Specifically in penetrating injuries including gunshot wounds, injuries most likely to cause death are a result of internal and/or external hemorrhage, catastrophic brain injury, and penetrating chest trauma resulting in compromised breathing due to pneumothorax or tension pneumothorax. Of these injuries, there are several components in gunshot trauma kits that can increase the odds of survival until definitive care is reached. These components include: Tourniquet 2 chest seals Wound packing gauze Pressure dressing Trauma shears 1-2 pairs of nitrile or vinyl disposable gloves QuikClot or Celox Hemostatic gauze (optional) Nasal airway with lubricant (If trained) Chest Spike or Decompression needle (Only if trained) Tourniquets A CAT-7 tourniquet is one of several recommended by the Committee for Tactical Combat Casualty Care. One of the more recently approved options to consider is the SAM-XT by SAM Medical. There are many great training videos on both manufacturers’ websites. What do the civilian trauma societies say about tourniquets? The big guns of trauma in the U.S., the American College of Surgeons, Pediatric Trauma Society, and Advanced Trauma Life Support (ATLS), provide guidelines recommending training for everyone in bleeding control and the application of a tourniquet if direct pressure and pressure dressings fail to control bleeding. They don’t recommend specific manufacturers of tourniquets, but all agree that purpose-built, manufactured tourniquets are preferred over improvised versions. You can find a Stop the Bleed training class and download a free brochure on how to recognize and treat life-threatening bleeding using tourniquets and wound packing at Bleedingcontrol.org. You can also search for a free Stop the Bleed class in your area on the site, and learn how to become an instructor. The most important thing to consider in choosing your tourniquet is whether you know how and when to use it. Wound Packing Gauze, With or Without Hemostatic Agent Wound packing gauze is used to fill gaps caused by penetrating wounds to the groin, armpits, or extremities. It isn’t recommended for use in the abdomen or chest. The theory behind wound packing is simple: If you can fit a finger into the wound, you should pack it before applying a pressure dressing. The reason for this is because if there’s a large channel in the wound, there are likely broken blood vessels leaking into the space. Applying external pressure on top of the wound will still allow bleeding into the space. If you pack gauze tightly into the space, you’ll stop the bleeding deep in the wound. Plain wound packing gauze is very inexpensive. There are many generic brands out there. This is one item where you can save a little in order to splurge on a brand-name tourniquet or better set of trauma shears. Alternatively, you can upgrade to gauze treated with a hemostatic agent that promotes faster clotting, such as QuikClot or Celox. I prefer the QuikClot rolled gauze in my kit, because it can be used as wound packing or as roller gauze for an additional pressure dressing on an extremity. Chest Seals Chest seals are used whenever there’s a penetrating wound to the chest. Normally, the lungs sit inside the chest cavity with nearly no space between the lining of the cavity and the surface of the lungs. There’s always a negative pressure, or vacuum, keeping the lungs gliding along the chest wall with normal breathing. Any interruption in that space, such as from a bullet wound, causes the vacuum to be lost and allows the lung to collapse. At first, there’s just a little air space and the victim can compensate. However, if the wound isn’t sealed, with each breath, more air sucks into the wound. You can sometimes hear the audible suction of the sucking chest wound. In time, if all of the wounds aren’t sealed, the lung collapses completely and then starts to compress the heart and large blood vessels, which are situated between the lungs. If this pressure is allowed to persist, the blood cannot be returned back to the heart for distribution, and the victim dies of shock and lack of perfusion. The reason you cover all chest wounds with an occlusive dressing is to prevent this complication, which is rapidly fatal and somewhat preventable. Chest seals can be purpose-built, but they can also be improvised by using any airtight material and securing it to the chest to cover any and all chest wounds. Really, they should be thought of as thorax seals, because the thoracic cavity has a backside as well. Don’t forget to roll the victim and look at the back, under the arms, and down both sides of the chest. I carry either improvised chest seals consisting of two Vaseline gauze pads and duct tape, or the Compact Hyfin Vent chest seal twin pack made by North American Rescue. Both are effective, but the NAR commercial chest seals offer an advantage as far as convenience and how quickly they can be deployed. Pressure Dressing I consider this item to be essential, but it’s also easily improvised. It’s basically a pad of some kind, such as a couple of 4×4 gauze pads, secured pretty tightly by a circumferential dressing. This could be an ACE wrap, a roll of gauze, or athletic tape. The idea is to compress the blood vessels at the site of the wound and slow the bleeding enough for your body’s own clotting to do its job. In a gunshot trauma kit, for the sake of keeping the contents to a minimum, I use the North American Rescue Mini Responder 4-inch Emergency Trauma Dressing (ETD). There are other pressure and trauma dressings out there of various sizes and pricing levels. My only advice is to make sure the dressings aren’t too bulky, because if there’s too much padding, there won’t be enough pressure over the wound — then all the dressing will do is absorb the ongoing bleeding until it’s full. The American College of Surgeons Committee on Trauma recently updated the Stop the Bleed class slides to reflect their recommendation that a tourniquet be applied if wound packing and pressure dressings fail to control bleeding. In my experience, most bleeding can be controlled with direct pressure, pressure dressings, and wound packing. A good pressure dressing is one of the essential components of the gunshot trauma kit. Other Components Trauma shears should always be included in any med kit. You can’t treat what you don’t see, and that means exposing the injury. You don’t think about trying to get jeans or gear off of someone with broken bones and bad soft tissue injuries, but when you encounter them, you’ll be glad you have shears. My personal set I use every day in the trauma bay and ER are the Leatherman Raptor shears. I also have gloves in all kits for personal protection from exposure to body fluids such as blood. Two more components in my personal GSW kit include a nasopharyngeal airway and chest decompression needle. However, it cannot be overstated that these items require training and can actually do more harm than good in untrained hands. Nasal airways shouldn’t be used in cases where there’s facial trauma, as it could potentially push broken bone fragments into the brain. Chest decompression needles can cause a pneumothorax if one wasn’t already definitely present. It could also penetrate major blood vessels or other vital structures in the chest if not placed in the correct location. Even trained paramedics sometimes get the placement or the indication for the intervention wrong, so you can bet that an untrained individual might have an even greater chance of making a mistake. Individual First Aid Kit (E-IFAK) Components My ideal kit that I take everywhere and have in my vehicle at all times is one I call the Off-Road Trauma Kit. In designing my kit, I thought of all the common injuries and medical conditions I might encounter where medical assistance might be delayed. This kit is far more comprehensive than my bare essentials, gunshot trauma kit, since it can be used to treat so much more than gunshot wounds. The components include the following: CAT-7 tourniquet QuikClot hemostatic gauze 3 pair disposable gloves 4×4 gauze 2 petrolatum gauze and 36-inch duct tape (improvised chest seals) 2 triangular bandages (for sling and splinting, multiple uses) Trauma shears 36-inch SAM splint – can be folded or cut into multiple configurations 3-inch ACE wrap CoFlex athletic tape Roller gauze, 3-inch Mylar blanket (for cold exposure) Small cold/ice pack CPR face shield Eye kit – eyewash, two oval eye pads, tape strips Wound kit Small and large steri strips with benzoin swab for better adhesion Antibiotic ointment packets Betadine pads or swabs Band aids Hand cleaning wipes Essential medication kit Benadryl for allergies/allergic reactions Acetaminophen or Tylenol – best choice if suspected head injury or internal bleeding suspected Ibuprofen or Advil/Motrin – worsens bleeding; don’t use in head injury Aspirin – for suspected heart attack. Also worsens bleeding. Zantac – for upset stomach but also for allergic reactions Glucose gel – for diabetic emergencies Hydrocortisone cream packets – for itch/rash Insect sting relief wipes Many of the items listed above are multipurpose and cover multiple injuries/minor illnesses. You can find most of these components on Amazon or other websites. Building and maintaining a gunshot trauma kit and comprehensive first aid kit containing the components listed in this article will equip you to handle the types of medical emergencies and injuries shooting, hunting, and outdoor enthusiasts are most likely to encounter. Ensuring you’re truly prepared to handle them requires some basic training, which you can achieve in a formal class, or by training yourself with some of the reputable sources on the internet and YouTube. Armed with both a comprehensive medical kit and training, you’ll significantly improve the chances of survival for yourself and those around you. 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