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

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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.

'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

Quote:

Originally Posted by 52bravo

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

Quote:

Originally Posted by swatsurgeon

rural setting scenerio.......IED goes off on farm land, raising some type of animal

Quote:

Originally Posted by swatsurgeon

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

. 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