PDA

View Full Version : Difficult to Control


swatsurgeon
03-04-2008, 13:59
rural setting scenerio.......IED goes off on farm land, raising some type of animal,
passenger in lead vehicle takes the brunt of the blast, rips the door off and his right arm at the shoulder.

What is YOUR management of.....
1. Control of hemorrhage,
2. field wound management
3. CASEVAC issues
4. hospital/aid station issues

Red Flag 1
03-04-2008, 14:27
Great case! Severed arm looks pretty good. Can't have enough clamps in the field.

RF 1

sofmed
03-04-2008, 14:35
Someone performed some incredible hemorrage control to get him to higher, as it's obvious he's on a bed or gourney of some sort. Hats off to the guy on the ground doing his job.

Will be keeping up with this one as you post more info.

Cheers!

Mick

Doczilla
03-04-2008, 23:01
I couldn't help but notice the EZ-IO identification bracelet.... on the severed arm. :confused:

'zilla

adal
03-04-2008, 23:21
1. Advanced airway w/ c-spine. Wound to rt cheek and blast on that side would tell me massive baro trauma as well.
2. Ready to suction. Monitor breath sounds as best as poss.
3. Ligate, ligate, ligate. Hemostatic control agent. Package tight. Multi large bore IV. I like the IO. Bilat if poss.
4. Airevac to Neuro and vascular surgery. Pack limb to go with.
5. Be ready for a combative patient unless you have RSI or sedation meds.

Great case. How was the outcome, if I can ask. Thanks. adal

swatsurgeon
03-05-2008, 09:09
I couldn't help but notice the EZ-IO identification bracelet.... on the severed arm

- Dczilla, the patient was so hypotensive, no peripheral access was able to be obtained so they inserted an EZ-IO in the tibia.

1. Advanced airway w/ c-spine. Wound to rt cheek and blast on that side would tell me massive baro trauma as well.
2. Ready to suction. Monitor breath sounds as best as poss.
3. Ligate, ligate, ligate. Hemostatic control agent. Package tight. Multi large bore IV. I like the IO. Bilat if poss.
4. Airevac to Neuro and vascular surgery. Pack limb to go with.
5. Be ready for a combative patient unless you have RSI or sedation meds.

Great case. How was the outcome, if I can ask. Thanks. adal

adal, airway was secured with ETT once arrived at hospital, he was breathing spontaneosly and airway was not compromised....could have become that way with the effects of a blast injury, intubation at any point would be okay but IMHO, after getting hemostasis if he is breathing.
Ask yourself a question, which vessel, axillary/subclavian ARTERY or VEIN will be the one to let you bleed out the quickest??
The artery has muscle in it's wall and typically will close itself off quickly which is what happened to this guy, The vein is thin walled and has no such contraction properties and will remain an "open faucet" until pressure is applied or it is ligated. DIRECTED pressure was held to the site of bleeding, not a big bulky 'pressure dressing'...that would have allowed him to continue hemorrhaging and die. Could you use a hemostatic agent, hell yes, put quik clot on it hold fast...sorry, no tourniquet on this one, can't place it above the site, no purchase to hold on to the entire arm is gone.
Limb went with him but under the circumstances of maximal 'dirty' conditions with disrupted bone, soft tissue, nerve and artery and vein (not a clean 'saw type' cut), the arm isn't going to be re-implanted.
Remember, this is rural and farm country....must use a penicillin type drug, in addition to others,, very specific bacteria with farms, etc, CAN'T forget this.
evac where a surgeon can take care of bleeding, nerve is way down the list of priorities for this particular injury.
Look for other injuries: chest penetration...hate to stop bleeding and have him die of a missed tension pneumothorax!

Intra-op pics attached: showing socket of shoulder, dealing with vessels and nerves, showing non-implantable staus of soft tissues/muscles.

He survived the operation, 8 units of blood, had a significant metabolic acidosis requiring aggressive resuscitation. I thought his shock state would kill him but he survived and improved with alot of work/efforts. No other major injuries other then his ear hanging off that we fixed in the ICU. Managed the nerve appropriately to minimize post op phantom pain.
More later.

ss

Fonzy
03-05-2008, 10:02
Being a regular leg, what would we be able to do being put in that situation? I can't think of anything in a CLS bag that would stablize long enough for a medic or medivac.
SPC Fiorella

52bravo
03-05-2008, 11:25
good case doc!!

i dont spent allot of time, on the no TQ bleeding.

tells us why the EZ-IO tag, is one that arm?

swatsurgeon
03-05-2008, 12:12
good case doc!!

i dont spent allot of time, on the no TQ bleeding.

tells us why the EZ-IO tag, is one that arm?

That was the real question...why was the EZ-IO tag on the amputated arm????
When I asked the medic he said it was the closest extremity to him when he had the tag in his hand, and he knew it was coming with the patient...he realized the 'mistake' once they started transport and he laughed about it with us. Should have been on the other arm or either leg. I didn't have the heart to write it up as a problem for his medical director, he figured out the problem, education accomplished in my book.

52bravo
03-05-2008, 14:09
ok - i agree on not write it up, if he can get one, like that to you alive, and he know it "wrong" - he still don a h... of a job!.

this case really make me think, what to do if the bleeding, is so deep you can pack or clamp?

i think i will try a big foley ( 20-22f ) - never tryed it, i have use tournicath, on live tissue, it works.

how easy is to, tire of vessel via a thoracotomy?

adal
03-05-2008, 20:59
Doc,
Agree with watch for Pneumothorax. Agree with which vessel to ligate. (One that is leaking the most.) Great scenario.

I put neuro doc on the list because of "possible" head injury secondary to blast. Not necessarily arm reattachment.

Anything I can do in the field to reduce acidosis complications besides adequate respirations and fluids? Monitoring In and Out. We have Foleys if we have time.

With my air job we start "war wound" antibiotic therapy. (We have an RN on board.)

On a side note: What happened with the Neck scenario one you did earlier?

Thanks Doc.
adal

frostfire
03-06-2008, 16:31
rural setting scenerio.......IED goes off on farm land, raising some type of animal

Remember, this is rural and farm country....must use a penicillin type drug, in addition to others,, very specific bacteria with farms, etc, CAN'T forget this.

thank you for mentioning this, swatsurgeon. I was itching to write prophylactic, prophylactic, prophylactic...but was afraid to be wrong and looked foolish :o. I still have much to learn, but this boosts my confidence

swatsurgeon
03-08-2008, 13:49
So, a moth later, he's healed and ready for a skin graft with the hopes of getting fitted for a prosthesis.
The stretch of the nerve that I couldn't get to is causing him alot of grief. Tried neurontin, now swtitching to lyrica and mentioned the mirror trick and he's following up with a rehab doc.
No infection thank goodness and an excellent recovery.
Time from injury to OR was about 90 minutes.
Will give more info after I see him next week.

Red Flag 1
03-08-2008, 16:32
SS

Great work! I've been impressed in what I have learned about mirror therapy. He may not have enough muscle left to work with but it is worth a shot. Amitriptyline 100mg-150mg @ hs has also been tried with some success ( start with 50mg and work up). Keep me posted.

How's the elbow?

RF 1

sofmed
03-08-2008, 18:30
SS,

I'm so amazed at what the human body is capable of, especially when someone who is educated in the right skill-set (meaning surgeons such as yourself) are able to guide or direct the body in the process of healing and recovery.

Thank you for what you do. Also, to mirror Red's ???, how's the arm?

Wishing you the best!

Mick

swatsurgeon
03-09-2008, 09:24
I would love to take credit but the human body deserves the credit. A surgeon, medic, nurse or who ever is a facilitator...the body just has to be given all of the support and tools to heal itself. Yes, surgery, a procedure assists or can begin the process but the 'miracle' is the body itself and deserves the credit.

My arm is doing better....about 85% extension, but still lets me know when I reach any limits with movement by invoking the blow torch feeling in the elbow. I have been able to begin operating again and doing okay so far, just no weight bearing (or shooting) for 2.5 more months...that is a true pain in my butt.

ss

sofmed
03-10-2008, 14:08
just no ... (or shooting) for 2.5 more months...that is a true pain in my butt.

ss


I defininitley feel your pain. When I had my second arthroscopic hip surgery to repair the labrum and the psoas ligament, among other torn connective tissues I was unable to run for months, and total time for both surgeries was close to a year without running. For a former jr. triathlete that just plain sucks. :(

Looking forward to hearing that you're continuing to recouperate well. :lifter

Cheers!

Mick

Books
03-11-2008, 17:22
Getting to this one late. . . too much work makes Books an absent boy.

To the Docs. . . Thanks much for this. We need these cases.

I would add, for the medics in the field who are not able to very quickly get their patient to a FAST or the like, remember that while the arteries will clamp shut on their own, after about 20-30 minutes, they will relax and resume bleeding out. So, as will all treatments, reassess to make sure your hemcon/mosquitos/quickclot/what-have-you is holding the red stuff in. Nothing is a fire and forget. . .

I too would like to know more about preventing the acidosis in the field. Would administering bicarb have been useful in this instance? Thanks in advance.

Books

Heretic
03-11-2008, 20:38
"I too would like to know more about preventing the acidosis in the field. Would administering bicarb have been useful in this instance? Thanks in advance."


There are several things out there to help fight acidosis. Factor VII is being used limited. This is expensive and has to be temperature controlled. The thought process is that once the body is wounded you have a cascade effect. Shock, youíre not going to stop it just control it. The body does its magic of trying to heal itself by flooding the injured area with clotting factors. The area is going to swell and if a tourniquet was used compartment syndrome comes into play. Throw hypothermia in there and the recipe for acidosis is complete. Your treatments can be spot on and you initially saved the life but days, weeks or even months down the road the PT experiences difficulty due to acidosis. This is all compounded by the coagulation. You dump some fluids in this guy/gal and the body relaxes from the shock and you have a flood of bad stuff traveling out systemically. pH levels are changed by the injury, treatments and the body. Consider acidosis the primer. You control that and the outcome is better for the patient. This is illustrated by the triangle or pyramid of death.

Hypothermia
Coagulation
Acidosis
(I might have this wrong. Its late and the beer is slurring my typing.)

Plus I donít have access to my med drive right now

swatsurgeon
03-12-2008, 05:58
The etiology of the acidosis is what needs to be addressed. Remember, acidosis is a result of a generalized/localized shock state = the metabolic demands of the tissues are NOT being met and anaerobic metabolism is occuring to produce energy at the cellular level.
That being said, fix the initial problem and the acidosis will/should resolve. Here is the problem: the more acidotic, the slower the body will turn this around with giving it back fluid, blood, etc. This is where giving adjuncts helps, i.e., bicarb or THAM.
Interesting facts: a pH greater than 7.28 generally won't screw up enough enzyme systems to kill you and should reverse with resuscitation. A pH between 7.2 and 7.27 should be vigorously treated since ~ 50% of all body enzyme systems are now dysfunctional, you begin to see body processes going out of wack: arrhythmias and the like. Below 7.2, > 80% of all enzyme systems quit...now you're screwed. This is why literature in surgery/medicine and Trauma all say the chances of survival with a pH below 6.8 are slim to none. ... not zero but damn close.
Now what can you do in the field......
STOP THE BLEEDING, give small volumes of fluid, make sure the patient is moving air (ventilating and oxygenating). Do not give bicarb...makes the hemoglobin NOT want to give up O2 that it has bound and removes the respiratory compensation your body is doing all by itself.
The body is an amazing thing....it will compensate for a long time if you stop the insult and allow it to begin/continue to compensate.

ss

swatsurgeon
03-12-2008, 07:41
"I too would like to know more about preventing the acidosis in the field. Would administering bicarb have been useful in this instance? Thanks in advance."


There are several things out there to help fight acidosis. Factor VII is being used limited. This is expensive and has to be temperature controlled. The thought process is that once the body is wounded you have a cascade effect. Shock, youíre not going to stop it just control it. The body does its magic of trying to heal itself by flooding the injured area with clotting factors. The area is going to swell and if a tourniquet was used compartment syndrome comes into play. Throw hypothermia in there and the recipe for acidosis is complete. Your treatments can be spot on and you initially saved the life but days, weeks or even months down the road the PT experiences difficulty due to acidosis. This is all compounded by the coagulation. You dump some fluids in this guy/gal and the body relaxes from the shock and you have a flood of bad stuff traveling out systemically. pH levels are changed by the injury, treatments and the body. Consider acidosis the primer. You control that and the outcome is better for the patient. This is illustrated by the triangle or pyramid of death.

Hypothermia
Coagulation
Acidosis
(I might have this wrong. Its late and the beer is slurring my typing.)

Plus I donít have access to my med drive right now

it is the failure to coagulate which is the problem.. Compound this with hypothermia, your platelets won't work making the coagulopathy worse. Acidosis, based on my previous post: decrease the pH enough and enzyme systems (part of initiating and maintaining coagulation) are shot. Badness at every turn.

ss

swatsurgeon
03-12-2008, 07:43
"I too would like to know more about preventing the acidosis in the field. Would administering bicarb have been useful in this instance? Thanks in advance."


There are several things out there to help fight acidosis. Factor VII is being used limited. This is expensive and has to be temperature controlled. The thought process is that once the body is wounded you have a cascade effect. Shock, youíre not going to stop it just control it. The body does its magic of trying to heal itself by flooding the injured area with clotting factors. The area is going to swell and if a tourniquet was used compartment syndrome comes into play. Throw hypothermia in there and the recipe for acidosis is complete. Your treatments can be spot on and you initially saved the life but days, weeks or even months down the road the PT experiences difficulty due to acidosis. This is all compounded by the coagulation. You dump some fluids in this guy/gal and the body relaxes from the shock and you have a flood of bad stuff traveling out systemically. pH levels are changed by the injury, treatments and the body. Consider acidosis the primer. You control that and the outcome is better for the patient. This is illustrated by the triangle or pyramid of death.

Hypothermia
Coagulation
Acidosis
(I might have this wrong. Its late and the beer is slurring my typing.)

Plus I donít have access to my med drive right now

it is the failure to coagulate ( coagulopathy) which is the problem.. Compound this with hypothermia, your platelets won't work making the coagulopathy worse. Acidosis, based on my previous post: decrease the pH enough and enzyme systems (part of initiating and maintaining coagulation) are shot. Badness at every turn.

ss

Red Flag 1
03-12-2008, 09:15
Are the 18D's taking Bicarb in their aid bags?

RF 1

Heretic
03-12-2008, 09:26
it is the failure to coagulate ( coagulopathy) which is the problem.. Compound this with hypothermia, your platelets won't work making the coagulopathy worse. Acidosis, based on my previous post: decrease the pH enough and enzyme systems (part of initiating and maintaining coagulation) are shot. Badness at every turn.

ss


Yes, I was trying to somewhat get that out last night. Thanks for the insight.

Books
03-18-2008, 21:55
Are the 18D's taking Bicarb in their aid bags?

RF 1

Not in the bag.. At least I'm not. Though it was discussed while in the course by civilian paramedics as a part of their cardiac protocols (though they were in the process of removing it).

Red Flag 1
03-19-2008, 10:54
18 Ds,

I would find it interesting to learn how many 18Ds are using Sodium Bacarb in the field? That's the injectable kind gents!

RF 1

Heretic
03-19-2008, 12:06
I do not carry it. I fail to see the practical application for it. You have no way of measuring the patient's acidotic state. If you are taking labs on the OBJ your priority in treatments needs to be realigned. We carry I-stats in our vehicle bags and that is for the rare case we have to sit on a patient for some time. You want to reduce acidosis? Treat the wounds effectively, treat for hypothermia (even during summer), diligent fluid resuscitation. Let the body maintain the pH. Its way better then you flooding it with fluids and causing fluid shifts hampering the pH more. Not to forget about causing leaky veins etc. On the "X" it does not matter if you are an 18D, 68W or a Trauma doc, all we are is a preventive measure against death. Stay focused on the best medicine for your patient and giving it when it is needed. Example obtaining a ABG is useless if your PT is not breathing.

Red Flag 1
03-19-2008, 12:14
heretic,

Thanks

adal
03-19-2008, 13:44
As an 18D I never carried bicarb. As a civilian ground medic, we carry it but very rarely use it. If we do it's more for an overdose. As a flight medic we carry it and use it a little more often, but even then very sparingly. We had I-stats but put them aside since our usual flight times aren't any longer than 90 min. (Yes it depends on how long the pt was down, type of injury, but we couldn't justify it where we're at.) adal

sofmed
03-19-2008, 13:51
On the "X" it does not matter if you are an 18D, 68W or a Trauma doc, all we are is a preventive measure against death. Stay focused on the best medicine for your patient and giving it when it is needed. Example obtaining a ABG is useless if your PT is not breathing.

I couldn't have said it better myself.

Cheers!

Mick

Heretic
03-19-2008, 13:58
I am here to serve.

Let me caveat my statement by saying that I am not down playing anyone's skills here. I am saying that there is a proper time and place to use those skills. As an 18D you possess a greater knowledge then the common 68W. Prior to TCCC 68W were not capable of handling trauma correctly. (This is a blanket statement. I do not mean to include every single medic out there, just the majority). The upside of combat is you quickly learn your weaknesses in all matters. Medicine included hence TCCC. Now I see 68Ws that can run a pretty sweet CTM lane. Same goes for PAs, DOCs etc that come to get a taste of trauma. Your skills and knowledge are great but the place and timing may be wrong to use them. When you witness 5 medics and a PA standing around your team mate laying naked on a talon with half his blood under him, not in him, you start to understand that if you fail to master the basics you are no expert, you have no advance skills. You are at a minimum a witness to death if not a collaborator.