Extremity Trauma

[swatsurgeon]

new case for management...allow me some liberties in the story.

soldier hit in right arm by 7.62/.308 round. No armor covering this area, just long sleeves on BDUs. Entrance from his right side.

[shadowflyer]

Originally posted by swatsurgeon
new case for management...allow me some liberties in the story.

soldier hit in right arm by 7.62/.308 round. No armor covering this area, just long sleeves on BDUs. Entrance from his right side.


LOC ...AVPU
Airway, Open and Clear
Breathing, RRQ
Circulation--Radial Pulses? CRT's? Skin Characteristics?

Major bleeding controlled?

Rapid head to toe Trauma ASSMT.

Load and Go due to MOI of GSW.

Secondary survey to make sure I didnt miss anything on the head to toe.


DX-GSW to RT humerus at the proximal end of extremity. Entrance wound on the posterior with an exit on the anterior side of arm.

TX--Dress with moist sterile dressings, Immobilize as best as I can.

Hang 2 16-18 G IV NS run them wide open to keep Systolic above 100mm/hg as I know he is going to be shocky.

O2 Therapy 15 l/min NRB.

Pain Mgmt with 8-10 MS IV push with 12.5 of Phenegran for nausea.

Call for EVAC ...he is going to need a surgeon if there is any chance of saving his arm.

Jason

[NousDefionsDoc]

Excellent thread Doc

Why moist dressings?

How do you know he's going to be shocky?

[shadowflyer]

Originally posted by NousDefionsDoc
Excellent thread Doc

Why moist dressings?

How do you know he's going to be shocky?

I chose moist due to the amount of internal tissues involved.


I dont know I guess I should have said ...I assume he would be shocky...I dont know for sure without a BP measurement for this PT. I was thinking the bullet could have gotten the brachial artery as it is right in that area. Lots of blood loss untiil we could get the bleeding controlled.

JJ

[NousDefionsDoc]

Don't doubt yourself, I was just asking.:D

[swatsurgeon]

Jason,
a few points...
1) pressure of 80 is wonderful, especially in penetrating trauma. To much fluid does a few bad things. First, the higher the BP the faster the bleeding and the "pop" the clot syndrome, second, the more dilution the worse the coagulation cascade can function. Avoid pressure >80 until definitive care can be rendered. All organ systems will do fine with function with a SBP ~80. It's actually based on the mean BP but we make allowances in the field since a SBP is quick to get, remember, a femoral pulse roughly = SBP of atleast 70, brachial of atleast 60 and carotid at least 50....too low; DANGER!! give fluid until femoral back up to palp.
2) moist dressing appropriate unless big burns
3) think of what kills people with this injury.....hemorrhage, therefore tourniquet ASAP just tight enough to stop the bleeding and no tighter....look closely at the pic and you can see where the tourniquet was applied.
4) neuro/vascular assessment a must when it is safe to perform.
5) remember the artery has a muscular wall and will constrict on its own to slow bleeding and maybe even stop it for some time. The veins have no such muscular layer and are the cause for bleed outs in the majority of cases. This is where traumadex, 'loose' tourniquet, tight dressing wrap can all come together to save a life but probably not this arm.....have to wait to see....will need multiple operative debridements, attempts at stabilization of bone fractures and vascular repain as indicated.
T-2

[shadowflyer]

Originally posted by swatsurgeon
Jason,
a few points...
1) pressure of 80 is wonderful, especially in penetrating trauma. To much fluid does a few bad things. First, the higher the BP the faster the bleeding and the "pop" the clot syndrome, second, the more dilution the worse the coagulation cascade can function. Avoid pressure >80 until definitive care can be rendered. All organ systems will do fine with function with a SBP ~80. It's actually based on the mean BP but we make allowances in the field since a SBP is quick to get, remember, a femoral pulse roughly = SBP of atleast 70, brachial of atleast 60 and carotid at least 50....too low; DANGER!! give fluid until femoral back up to palp.
2) moist dressing appropriate unless big burns
3) think of what kills people with this injury.....hemorrhage, therefore tourniquet ASAP just tight enough to stop the bleeding and no tighter....look closely at the pic and you can see where the tourniquet was applied.
4) neuro/vascular assessment a must when it is safe to perform.
5) remember the artery has a muscular wall and will constrict on its own to slow bleeding and maybe even stop it for some time. The veins have no such muscular layer and are the cause for bleed outs in the majority of cases. This is where traumadex, 'loose' tourniquet, tight dressing wrap can all come together to save a life but probably not this arm.....have to wait to see....will need multiple operative debridements, attempts at stabilization of bone fractures and vascular repain as indicated.
T-2


Thanks for the lesson Sir. I appreciate your willingness to help us out with teaching.

We are taught in class to keep the BP around 90-100 systolic with fluid challenges. I can see where TOO much fluid can do what you are talking about, just never had it explained that way.


The only field experience I have at this time is clinical setting at a Level 2 trauma center and with a few rides on a Rescue. I am riding again tomorrow for 12 hours, so hopefully I will get some good calls to work on.


Thanks again Sir,

Jason