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Doc Dutch
07-07-2009, 10:01
So, I get a call from a physician across town that they have a 20ish year old male. He has sustained a deep laceration to his left popliteal space. He is hemodynamically stable and that there does not seem to be "too much bleeding" coming from the wound but that the physician is worried because the wound goes deep and that he feels it needs to be closed in the OR. In fact the physician casually mentions that the patient even drove himself to their hospital. So . . . he has called the trauma center and wants to transfer the patient.

Thoughts? Let me just add that nothing is ever as advertised! Give me some thoughts here as to what anyone would want to know. I will hold off sending pictures until I have a few responses and give you more detail. I want ideas as to what you might ask that physician about his physical examination, treatment there at his ED and possible treatment en route and mode of transport the patient might take to you. Also, would anyone speak to the nursing staff or have their nursing staff speak to the transferring nurses or flight crew?

Dutch

Red Flag 1
07-07-2009, 13:39
Referal calls from anyone, including referring physicans, are a subjective event.

What was the mechanism of injury? Did you probe the wound? What are the last vital signs? Are there distal pulses? Is there distal perfusion? Are you able to control bleeding without using a torniquete? Is the patient alert? Can the patient sit up without hypotension? Can the patient speak and understand the English language? Has a surgeon at your facility seen the patient,if so, may I speak with him? What is the single driving reason you are sending this paitent to me?

From what is presented, air evac is in the cards. Information from nurses , or anyone that knows the case on the ground, is of great value to the flight nurse/crew. In that transient care is placed in the hands of the flight crew, they need all the information they can get!

My $.02.

Like to know how this turned out :munchin


RF 1

CSB
07-07-2009, 14:50
Is the artery intact?

Doc Dutch
07-07-2009, 15:38
Referal calls from anyone, including referring physicans, are a subjective event.

What was the mechanism of injury? Did you probe the wound? What are the last vital signs? Are there distal pulses? Is there distal perfusion? Are you able to control bleeding without using a torniquete? Is the patient alert? Can the patient sit up without hypotension? Can the patient speak and understand the English language? Has a surgeon at your facility seen the patient,if so, may I speak with him? What is the single driving reason you are sending this paitent to me?

From what is presented, air evac is in the cards. Information from nurses , or anyone that knows the case on the ground, is of great value to the flight nurse/crew. In that transient care is placed in the hands of the flight crew, they need all the information they can get!

My $.02.

Like to know how this turned out :munchin


RF 1

Great questions, Red Flag.

The patient sustained a grinder injury to the left popliteal fossa. It is isolated and has sliced through the left posterior fossa. The physician had just rapidly bandaged the patient and did not "look deep" into the wound. He said the patient only lost a few hundred cc's of blood. Nothing about the scene and nothing about the blood loss in the car. Vitals were initially stated as "normal". As for distal pulses, the physician stated that they were normal and I "did not have to worry". They did not do orthostatics so I cannot comment. The patient is Spanish speaking with broken English. No surgeon there has seen the patient but I as the trauma surgeon at my institution am accepting the patient for transfer to our Level One trauma center. Again, the physician there tells me that he needs me to take him to the OR for closure and possible exploration but it probably does not go that deep. They do not have OR capabilities there interestingly enough.

Air Evac is an option as is ground. But . . . Yes, the nurses spoke to each other from hospital to hospital and that is where the "truth" gets told. Even the air crew nurses start calling our trauma center because everything is not as it appears and they have a very sick patient on there hands! They are calling for direction and to let us know they are coming in hot.

There is another response below. I will answer it and then we will continue on with the case!

Dutch

Doc Dutch
07-07-2009, 15:42
Is the artery intact?

Simply, it is hard to tell as we are not there to evaluate the wound but the physician calling is very nonchalant about the injury and is more interested in just finding someone to send the patient, too. I can tell you that he did note that the patient had distal pulses in his foot on the injured side. He said that it was not as strong as the uninjured side because of the dressings?

Dutch

Doc Dutch
07-07-2009, 16:05
They had two large bore IV's and the air crew was starting a third just in case. The patient was on hundred percent O2 by FM. At the referring ED, they stated that he had breakthrough bleeding and they had to reinforce the bandage twice. The air crew stated that after he arrived to us he had lost at least 2 liters of blood in the ED and on the gurney in their helicopter. The patient had a RR of 40 breaths per minute and was cold and sweating. The air crew was calling stating that they were giving more fluid boluses and starting the blood. They also notified us that they were going to apply a tourniquet to the thigh.

We upgraded the patient from consult status to our highest level of activation and the trauma team was waiting for the patient on arrival in the trauma bay.

Thoughts? What about the blood? Would you or would you not transfuse? What are your triggers?
Tourniquet? Yes? No? Maybe?
Another adjuncts? Hemcon? Quikclot? Other topicals?

I am going to post two photos I took in the midst of the fray. I have blocked out the patient's face and doctor's partially masked face so not to reveal identities or give identifying information.

Dutch

Doc Dutch
07-07-2009, 16:13
They had two large bore IV's and the air crew was starting a third just in case. The patient was on hundred percent O2 by FM. At the referring ED, they stated that he had breakthrough bleeding and they had to reinforce the bandage twice. The air crew stated that after he arrived to us he had lost at least 2 liters of blood in the ED and on the gurney in their helicopter. The patient had a RR of 40 breaths per minute and was cold and sweating. The air crew was calling stating that they were giving more fluid boluses and starting the blood. They also notified us that they were going to apply a tourniquet to the thigh.

We upgraded the patient from consult status to our highest level of activation and the trauma team was waiting for the patient on arrival in the trauma bay.

Thoughts? What about the blood? Would you or would you not transfuse? What are your triggers?
Tourniquet? Yes? No? Maybe?
Another adjuncts? Hemcon? Quikclot? Other topicals?

I am going to post two photos I took in the midst of the fray. I have blocked out the patient's face and doctor's partially masked face so not to reveal identities or give identifying information.

Dutch

Notice in these two photographs the tremendous amount of blood already lost in the dressings and gurney despite the twice reinforced bandage and the tourniquet. Mind you are seeing the wounds as everything is being peeled off or already being peeled off. This is on top of the 2 liters already lost. Vitals on arrival

BP 80/40, HR 130, RR 40, SaO2 91%

After you digest this, let's talk about your next steps. What would you do?

Dutch

Red Flag 1
07-07-2009, 16:45
Notice in these two photographs the tremendous amount of blood already lost in the dressings and gurney despite the twice reinforced bandage and the tourniquet. Mind you are seeing the wounds as everything is being peeled off or already being peeled off. This is on top of the 2 liters already lost. Vitals on arrival

BP 80/40, HR 130, RR 40, SaO2 91%

After you digest this, let's talk about your next steps. What would you do?

Dutch

When you said "grinder injury" the picture in my head was about the same as the photos.

I would suggest a pneumatic tourniquet for the surgical procedure. It will stop blood loss, and provide a clear surgical field. Tourniqute in the field might also be prudent if direct pressure will not stop the blood loss..

Pt is a bit shocky....RL first to volume expand, then cells .

You are in the OR for defenitive treatment, that is my arena as well, as for topicals, I must deferr to others. I would expect that there is quite a bit of soft tissue and tendon damage as well.

One thing I would do is to later phone the referring physician and "thank him for this most interesting consult"!

My $.02.

RF 1

Surgicalcric
07-07-2009, 17:01
How many units of blood was given by the flight crew? Has he been typed/crossed? How much crystalloids have been given?

Start with 2 units O Neg (if not T/C yet.) If T/C complete then admin appropriate.

H&H?
ETOH?
Drugs?
Medications?
History of how this happened?

I would agree with the pneumatic TQ for hemorrhage control, instead of the use of an HCA. Obtain a good view of the wound and its extend, and any other damage to surrounding structures. Depending on the physical exam films would also be in order.

Crip

Doc Dutch
07-07-2009, 17:28
After a few seconds of the tourniquet takedown in the trauma bay, this wound cut lose. The hemorrhage was not arterial as it did not spray out in a pulsatile fashion but was high flow, low pressure bleeding. We reapplied a bandage and had a faint pulse in the dorsalis pedis and posterior tibial. The Air Evac tourniquet was a pneumatic cuff and it did "OK".

We did the C-A-B-D-E trauma algorithm. That is, control the bleeding first and then move back to your A and B. His respiratory rate settled down with blood and eventual intubation as he had all of the hallarks of shock (class 3 at least). We pulled two units of O negative blood from the trauma bayrefrigerator and started to transfuse as he was white as a ghost. We continued with the IV resuscitation. The goal was to get vascular control ASAP and the only way to do this was going to be in the OR now! We knew from the air crew and the outside hospital nurse's reports that this was not just a flesh wound as had been painted for us by the referring physician. We gave him a tetanus shot, 2 grams IV Ancef and went straight to the OR.

No need for a pre-op angiograms or CT scans as we knew something was bleeding more than just the skin and muscle. That would have meant more time, more bleeding and no new information that we couldn't get in the OR.

While half of the surgery team scrubbed, I helped prep and drape the patient. A sterile tourniquet was applied. Once we were in the sterile field and the wound, we opened up the fossa in a medial popliteal approach and got venous/arterial proximal and distal control to be able to release te tourniquet. We had prepped the opposite groin in case we needed to harvest vein for a repair and we ended up using it. We found a transected politeal vein which we sewed back together primarily. The nerve was banged up pretty bad but not transected and besides he had minimal deficit on motor or sensory examination in the trauma bay. The artery was also partially transected and was on its way to thrombose. This is why it did not bleed on us in the trauma bay as it was already clotting off. So, we opened the artery, thrombectomized the clot and did a vein patch angioplasty. We reconstructed his muscles, tendons and skin and his post-op angiogram revealed a patent artery. We did complete a four compartment fasciotomy due to the length of time of arterial ischemia, tightness of the calf at the end of the case and prior hypotension. We sent him up to the ICU and did not extubate as he had over 10 liters of fluid, 12 units of blood and he was very swollen.

We extubated him on post-op day 2 (or 48 hours later). He was transferred onto the floor on ASA, Plavix and Coumadin to assist in keeping the repairs open. His pain improved and we had physical therapy ambulate him. He was discharged with follow-up.

Always assume the worse and that the history given is always missing something. Never take anything for granted and show up with your game face on. Always ask, re-ask and then ask again. Make sure the nurses and the air crew call report. Be there when the patient arrives so that you see the wound yourself and see how the patient is doing or responding to the therapy.

Here are some intraop photos and a photo of the post-op angiogram.

Dutch

Doc Dutch
07-07-2009, 17:37
How many units of blood was given by the flight crew? Has he been typed/crossed? How much crystalloids have been given?

Start with 2 units O Neg (if not T/C yet.) If T/C complete then admin appropriate.

H&H?
ETOH?
Drugs?
Medications?
History of how this happened?

I would agree with the pneumatic TQ for hemorrhage control, instead of the use of an HCA. Obtain a good view of the wound and its extend, and any other damage to surrounding structures. Depending on the physical exam films would also be in order.

Crip

Surgicalcric,
2 units were sent and one was transfused. They had not hung the second unit and we cannot not hang outside blood unless it comes from our in-house blood bank or is already hanging. We drew a type and cross and told them to activate our Massive Transfusion Protocol. I believe his starting H and H with us after arrival was 6/17.9 which tells you he was going even lower and had not reached his equilibrium point. I do not remember the EToH level but he was not on any home meds. The incident occurred at his construction work site about 15 minutes prior to his arriving at their ED. The only film we obtained pre-op was a quick A/P and Latral of the knee to see if there was a fracture so if ortho needed to be involved we could consult them. It took 30 seconds and I felt that was worth it, but I could have also obtained these intra-op after vascular control.

Dutch

Red Flag 1
07-07-2009, 18:03
Great case Doc Dutch!!!

Silly question, but I have to ask; did you place him prone in the OR or do this in a lateral postion? Also, did he require PEEP post-op in the unit?

Thanks again!!

RF 1

11Ber
07-07-2009, 21:05
This is why I come to this site. With permission I am printing and taking into to TCCC tomorrow to run through with the guys during lunch.

swatsurgeon
07-08-2009, 12:39
They had two large bore IV's and the air crew was starting a third just in case. The patient was on hundred percent O2 by FM. At the referring ED, they stated that he had breakthrough bleeding and they had to reinforce the bandage twice. The air crew stated that after he arrived to us he had lost at least 2 liters of blood in the ED and on the gurney in their helicopter. The patient had a RR of 40 breaths per minute and was cold and sweating. The air crew was calling stating that they were giving more fluid boluses and starting the blood. They also notified us that they were going to apply a tourniquet to the thigh.

We upgraded the patient from consult status to our highest level of activation and the trauma team was waiting for the patient on arrival in the trauma bay.

Thoughts? What about the blood? Would you or would you not transfuse? What are your triggers?
Tourniquet? Yes? No? Maybe?
Another adjuncts? Hemcon? Quikclot? Other topicals?

I am going to post two photos I took in the midst of the fray. I have blocked out the patient's face and doctor's partially masked face so not to reveal identities or give identifying information.

Dutch

he had breakthrough bleeding and they had to reinforce the bandage twice.
This is a classic case of uncontrolled hemorrhage with what people fondly refer to as a pressure dressing ....in reality it is nothing more than a "sponge" that soaks up precious blood and doed very little to slow/stop the hemorrhage...I really belive that these people dream in technicolor when they think a "pressure dressing" applied to a wound does something useful. The tourniquet should have been applied at this point, not when they are in the air. Where was it placed on the thigh by the air crew, was it tight enough to stop the bleeding, what tourniquet type was it?
Just for fun, I am adding a link to what has become my preferred tourniquet because it acts both as a pressure dressing that actually has physiologic results as a true pressure dressing and if wrapped as directed acts as a tourniquet.....by releasing 2 'wraps', it changed from tourniquet to pressure dressing when I tested it in the vascular lab.
The case report was my patient here.....it worked great.

http://swattourniquet.com/casereport.html

ss

Doc Dutch
07-08-2009, 15:33
Great case Doc Dutch!!!

Silly question, but I have to ask; did you place him prone in the OR or do this in a lateral postion? Also, did he require PEEP post-op in the unit?

Thanks again!!

RF 1

Great question. In an elective case I would have strongly considered the prone position, say for a popliteal aneurysm, however, as I had suspected that there was a venous injury, I knew or suspected that I was going to have to harvest vein. As the injured side's deep system was already compromised that really only meant he would be living off of his superficial system (saphenous vein) to drain the blood from his distal extremity and I did not want that system compromised. The result of the deep and superficial systems being compromised at the same time can be debilitating and life-long swelling of that lower extremity. So, I did the case supine to get access to the opposite uninjured lower extremity (saphenous vein). Thank goodness we did that as we needed that vein for the patch angioplasty of the artery.

As for the PEEP (positive end expiratory pressure) on the ventilator, yes, we started out I believe at 5 in the OR and went up to 8 to 10 post-op in the ICU. We subsequently weaned him down back to 5 as his body and kidneys diuresed the fluids.

Dutch

Doc Dutch
07-08-2009, 15:36
This is why I come to this site. With permission I am printing and taking into to TCCC tomorrow to run through with the guys during lunch.

Please, feel free to use it. There are no identifying features on the photos and the case has no identifying features in the scenario, so it is HIPPA compliant. Teaching our colleagues is critical for good outcomes in the future.

Good luck on the presentation.

Dutch

Doc Dutch
07-08-2009, 15:40
he had breakthrough bleeding and they had to reinforce the bandage twice.
This is a classic case of uncontrolled hemorrhage with what people fondly refer to as a pressure dressing ....in reality it is nothing more than a "sponge" that soaks up precious blood and doed very little to slow/stop the hemorrhage...I really belive that these people dream in technicolor when they think a "pressure dressing" applied to a wound does something useful. The tourniquet should have been applied at this point, not when they are in the air. Where was it placed on the thigh by the air crew, was it tight enough to stop the bleeding, what tourniquet type was it?
Just for fun, I am adding a link to what has become my preferred tourniquet because it acts both as a pressure dressing that actually has physiologic results as a true pressure dressing and if wrapped as directed acts as a tourniquet.....by releasing 2 'wraps', it changed from tourniquet to pressure dressing when I tested it in the vascular lab.
The case report was my patient here.....it worked great.

http://swattourniquet.com/casereport.html

ss

Wow! Now that is awesome!!! That is a great case on that website. I would recommend everyone going over and looking at it. Tourniquets are here to say and never should have left in the first place in my opinion. I am glad to see this website.

Dutch