Near amputation - What is your algorithm?

[Doc Dutch]

OK. This is a graphic account but is true. I almost did not relate this topic and images as some might not take this seriously but it is a very serious case. You must work through this exercise and go through the thought process. It is an excellent teaching case.

There is an IED explosion in Afghanistan while a team is returning to a FOB. The bottom of the MRAP is burned and rumbled but has not been breached. Fortunately, after a quick count and status check everyone is fine in the motor vehicle and convoy except the 22 year old technical sergeant with blood on his anterior ABU's pants. The blood came from somewhere (right?) and no one else is injured. One of the guys in the MRAP noted the blood as the TS is so wired by his near death IED experience he does not feel any pain (adrenaline/catecholamine surge). The astute combat medic immediately lays the TS down on the ground and cuts away his pants. The TS has sustained a penetrating injury from his own handgun. He refused to use a side belt holster in theater for his 9mm and he insisted in tucking the 9 mm in his belt with the safety off as he felt it was easier to level the 9 mm if needed. The 9mm discharged with the detonation and he was struck. The bullet entered the top of the penile shaft and exited from his perineum. He is immediately evacuated to Bagram AFB Medical Center. The patient keeps asking, "Are you going to cut my junk off ? Be honest with me, please. I haven't had kids yet, Please tell me the truth, doc!" (true story and you will be asked this question)

To the medics, what do you do first? What are your priorities? What do you need to consider? What do you tell the patient about an amputation?

To the physicians, where do you start? What do you do? What are your priorities? Let us just state that during this rotation at Bagram there is no urologist. So, what are you going to do? What is your algorithm?

I am posting images, however, this is for this website only as a medical teaching case. The photos have no identifying features and are HIPPA compliant. Please remember this is sensitive information but should be discussed for all providing combat casualty care in the field or at a medical center. It will happen. Be prepared.

DD

[Doc Dutch]

Originally Posted by Doc Dutch

OK. This is a graphic account but is true. I almost did not relate this topic and images as some might not take this seriously but it is a very serious case. You must work through this exercise and go through the thought process. It is an excellent teaching case.

There is an IED explosion in Afghanistan while a team is returning to a FOB. The bottom of the MRAP is burned and rumbled but has not been breached. Fortunately, after a quick count and status check everyone is fine in the motor vehicle and convoy except the 22 year old technical sergeant with blood on his anterior ABU's pants. The blood came from somewhere (right?) and no one else is injured. One of the guys in the MRAP noted the blood as the TS is so wired by his near death IED experience he does not feel any pain (adrenaline/catecholamine surge). The astute combat medic immediately lays the TS down on the ground and cuts away his pants. The TS has sustained a penetrating injury from his own handgun. He refused to use a side belt holster in theater for his 9mm and he insisted in tucking the 9 mm in his belt with the safety off as he felt it was easier to level the 9 mm if needed. The 9mm discharged with the detonation and he was struck. The bullet entered the top of the penile shaft and exited from his perineum. He is immediately evacuated to Bagram AFB Medical Center. The patient keeps asking, "Are you going to cut my junk off ? Be honest with me, please. I haven't had kids yet, Please tell me the truth, doc!" (true story and you will be asked this question)

To the medics, what do you do first? What are your priorities? What do you need to consider? What do you tell the patient about an amputation?

To the physicians, where do you start? What do you do? What are your priorities? Let us just state that during this rotation at Bagram there is no urologist. So, what are you going to do? What is your algorithm?

I am posting images, however, this is for this website only as a medical teaching case. The photos have no identifying features and are HIPPA compliant. Please remember this is sensitive information but should be discussed for all providing combat casualty care in the field or at a medical center. It will happen. Be prepared.

DD

One last thing, as I am leaving call for today. I will be back tomorrow to discuss what was done and how to deal with these injuries. Please relate what you would do for this patient and the work-up/care. I will be back to tell you what was done and see if anyone would have done something else or different.

Thank you,

DD

[Priest]

First and foremost, treat the pt. Don't mention amputation, stick with what you know. I'd have no idea what type of internal damage has actually been done, could only be out of "the game" for a few weeks for all I know. Convince him that he needs to calm down in order to prevent any further damage to himself. Get him talking as much as you can about something other than the obvious.

Then, assuming that the rapid trauma exam turns up no other wounds (superficial or signs of head injury) I'd suspect a possible pubic symphysis fracture, so I'd be wary of any log rolls. I would try and stop any hemorrhaging if present (I wouldn't suspect any major arterial involvement due to the anatomy.) I wouldn't be worried much about any tumbling due to the skin contact of the muzzle at the time of discharge.
As far as meds, I would establish IV access, most likely restraining the pt during this process. I would push Phenergan and morphine for pain. Standard war wound therapy would call for Rocephin as well.
Concerns would be for urethral tears, some suspensory ligament damage, and nerve damage.

[Red Flag 1]

Usual initial priorities. Questions to answer include: ebl enroute, how much active bleeding in trauma bay, can the bleeding be controled by direct pressure, is there normal anal sphincter tone, is blood being passed out the urethera, any rectal bleeding, is the patient hemodynamically stable?

Two large bore IV's, pelvis films, soft tissue studies if possible. This needs to be explored in the OR. Is this the time to try to pass an indwelling uretheral cath? Said cath can help with hemostasis if needed IMHO. Do have some concerns with bone frags if the projectile impacted any bone. Prostate, bladder and bowel issues need to be considered as well as pelvic vascular structures.. If there is much prostate damage, there could well be significant bleeding in the pelvis that could go undetected.....could see quite a bit of blood loss in surgery as well.

As for long term outcome, we do know from a celebrated case a decade or so ago, that the appendage can be re-attached after complete amputation. From the photos, the appendage does not look cyanotic and likely viable. Physiological function and reproductive abilities likely best determined in surgery and with post-op outcome, more than a bit out of my specialty here.

As for mechanism of injury....I doubt it will happen again with this solider.

Interesting professional subject.

My $.02.

RF 1

[Richard]

Battlefield KISS Principles ==> ABCDE ==> prep for surgery.

• A - Airway
• B - Bleeding
• C - Control shock (includes pain and psych mgt)
• D - Dress wound
• E - Evacuate expeditiously

Richard's $.02

[wook]

Vascular injury would be a concern, as would urethral tear. At some point early on I would do a RUG (Retrograde UrethroGram). If tear and no urologist to place the foley, probably try gentle placement of a foley (debate recently in literature about this). Obtain pelvic xray. I would probably also obtain CT pelvis (IV contrast). Also, concern for testicular injury...this can be evaluated by urologist ASAP (ie transfer). Get the rainbow (CBC, BMP, PT/PTT/INR, T&S). Also, a rectal exam would be helpful to see if gross blood (concern for injury of the GI tract/colon). Two large bore IV, O2, monitor.

Regarding amputation, advise him further studies are needed to fully evaluate the extent of the injury.


Wook

[Doc Dutch]

Originally Posted by Priest

First and foremost, treat the pt. Don't mention amputation, stick with what you know. I'd have no idea what type of internal damage has actually been done, could only be out of "the game" for a few weeks for all I know. Convince him that he needs to calm down in order to prevent any further damage to himself. Get him talking as much as you can about something other than the obvious.

Then, assuming that the rapid trauma exam turns up no other wounds (superficial or signs of head injury) I'd suspect a possible pubic symphysis fracture, so I'd be wary of any log rolls. I would try and stop any hemorrhaging if present (I wouldn't suspect any major arterial involvement due to the anatomy.) I wouldn't be worried much about any tumbling due to the skin contact of the muzzle at the time of discharge.
As far as meds, I would establish IV access, most likely restraining the pt during this process. I would push Phenergan and morphine for pain. Standard war wound therapy would call for Rocephin as well.
Concerns would be for urethral tears, some suspensory ligament damage, and nerve damage.

Yes . . . treat the patient and do not get engrossed by the nature or what the wound looks like. Agree. Do not mention amputation as that is likely not an issue as the majority of the appendage is there. I might recommend IV benzos or pain meds at this time to get him to relax as this is fairly benign despite a 9 mm going through penis which would concern any male and would be painful.

There were no other wounds (except a damaged ego) on initial evaluation. He was imaged with a Ct scan with IV and rectal contrast. Fortunately no fracture and no vascular injury but the penis is a vascular structure. The bleeding had stopped so no need to repair Bucks fascia in this setting just a simple wash out and bandage. Dressings were xeroform and gauze bunched up and held in place with a simple sling (can use burn netting or scrotal support. IV access is critical and part of the ABCDE's and it is what the medic did initially and a second one in the ED. He did get antibiotics and his tetanus was already up o date. Urethral tears are important and must be ruled out with a retrograde urethrogram. I have images to show. Nerve damage is a long term concern but the suspensory ligaments would not preclude ultimate function.

More to follow as per below . . .

DD

[Doc Dutch]

Originally Posted by Red Flag 1

Usual initial priorities. Questions to answer include: ebl enroute, how much active bleeding in trauma bay, can the bleeding be controled by direct pressure, is there normal anal sphincter tone, is blood being passed out the urethera, any rectal bleeding, is the patient hemodynamically stable?

Two large bore IV's, pelvis films, soft tissue studies if possible. This needs to be explored in the OR. Is this the time to try to pass an indwelling uretheral cath? Said cath can help with hemostasis if needed IMHO. Do have some concerns with bone frags if the projectile impacted any bone. Prostate, bladder and bowel issues need to be considered as well as pelvic vascular structures.. If there is much prostate damage, there could well be significant bleeding in the pelvis that could go undetected.....could see quite a bit of blood loss in surgery as well.

As for long term outcome, we do know from a celebrated case a decade or so ago, that the appendage can be re-attached after complete amputation. From the photos, the appendage does not look cyanotic and likely viable. Physiological function and reproductive abilities likely best determined in surgery and with post-op outcome, more than a bit out of my specialty here.

As for mechanism of injury....I doubt it will happen again with this solider.

Interesting professional subject.

My $.02.

RF 1

Agree with usual priorities. There was some blood loss en route (about a unit of blood but the bleeding stopped by arrival. Subsequent wash-out was necessary but little bleeding was encountered. Did not stitch up the wound and left it open as did not want to trap infection (did give antibiotics). Sphincter tone was normal with rectal examination. No blood was seen at the meatus and keeping careful watch to not cross contaminate, the blood was soaked up and pressure held to the perineal wound with the rectal examination. There was no blood found on rectal exam. The patient was hemodynamically stable at all times.

He was hemodynamically stable, pelvis films will be shown below. We did not need to explore as it turned out because the CT with IV and rectal contrast and delays were negative. We did need a retrograde urethrogram (RUG) however to assure the urethra was okay. An indwelling Foley can be passed only after the RUG and no urologist was needed. The CT helped us in regards to looking at the bone fragments, vascular injuries and soft tissues including the bowel.

The Bobbitt case (replant of the penis) has been repeated many times in the US. Most of the urogenital trauma in war zones are not simple lacerations or simple amputations and are more in line with severe debulking trauma or complete loss of the penis and/or testicles. Blast injuries with the directed force straight into the groin can be devastating and typically nothing to replant and unfortunately just debridement and dressing changes. His outcome is actually favorable in the case.

DD

[Doc Dutch]

Originally Posted by Richard

Battlefield KISS Principles ==> ABCDE ==> prep for surgery.

• A - Airway
• B - Bleeding
• C - Control shock (includes pain mgt)
• D - Dress wound
• E - Evacuate expeditiously

Richard's $.02

Thank you, Richard.

Exactly!!! ABCDE's Although "E" (exposure) was started first to ID the injury, the combat medic did the rest correctly after seeing what he had to deal with. Agree with evacuation expeditiously as time is tissue and life. I teach my residents all the time about the Kiss principle.

Now I have to run to the OR. when I get back I will post the additional photos or the RUG.

DD

[Red Flag 1]

Doc Dutch,

Do you see a reason for soldiers to add an "athletic cup" along with other armor? Granted this soldier would have seen little protection as this played out. Others may see the "cup" as a benefit. Your thoughts kind sir!

This was a lucky Dude!

RF 1

[Red Flag 1]

Originally Posted by wook

Vascular injury would be a concern, as would urethral tear. At some point early on I would do a RUG (Retrograde UrethroGram). If tear and no urologist to place the foley, probably try gentle placement of a foley (debate recently in literature about this). Obtain pelvic xray. I would probably also obtain CT pelvis (IV contrast). Also, concern for testicular injury...this can be evaluated by urologist ASAP (ie transfer). Get the rainbow (CBC, BMP, PT/PTT/INR, T&S). Also, a rectal exam would be helpful to see if gross blood (concern for injury of the GI tract/colon). Two large bore IV, O2, monitor.

Regarding amputation, advise him further studies are needed to fully evaluate the extent of the injury.


Wook

Bio??

RF 1

[Doc Dutch]

Originally Posted by wook

Vascular injury would be a concern, as would urethral tear. At some point early on I would do a RUG (Retrograde UrethroGram). If tear and no urologist to place the foley, probably try gentle placement of a foley (debate recently in literature about this). Obtain pelvic xray. I would probably also obtain CT pelvis (IV contrast). Also, concern for testicular injury...this can be evaluated by urologist ASAP (ie transfer). Get the rainbow (CBC, BMP, PT/PTT/INR, T&S). Also, a rectal exam would be helpful to see if gross blood (concern for injury of the GI tract/colon). Two large bore IV, O2, monitor.

Regarding amputation, advise him further studies are needed to fully evaluate the extent of the injury.


Wook

Yes. The worry was that he had a deep pelvis bleed or rectal injury but the trajectory through the soft tissues on CT did not show intra-abdominal of vascular injury. Rectal, PO and IV contrast were used. He was very fortunate. Again, I will post the RUG and then we placed a Foley once we had confirmation of no urethral injury. Testicles were not involved and there did not appear to be a blast effect. Again, no gross blood on rectal and good sphincter tone. Agree, two large bore IV's and O2 if available. Monitors are great if available like here in the states but not always available in theater.

DD

[Doc Dutch]

So, we have a hemodymanically normal patient with good vitals. He has stopped bleeding and his physical examination is normal except for the GSW to the base of the penis and an exit wounds to his perineum. CT of the abdomen and pelvis with IV, PO and rectal contrast are negative. There may be a small chip fracture of the anterior pubic bones but nothing that will require an orthopaedis pelvis operation to repair that chip. The trajectory looks like it hit the most anterior portion of the pelvis, chipped off a small piece of bone and the bullet fragmented leaving a small piece of fragment in his soft tissue anterior to the pelvis and a small fragment on the right side farther distal in the base of the penis.

Now there is no blood from the penile meatus. What we must make sure is that the urethra is okay and CT does not give you that information. A retrograde urethrogram will. This means that a foley ballon is passed through the penile meatus and partially inflated with 3 to 4 cc's of fluid. Under fluoroscopy dye is injected retroograde into the urethra and then into the bladder. A/P, lateral and oblque views are obtained. The bladder is also inspected for extravasation of contrast. Once completed the foley ballon is deflated and the Foley is passed into the bladder and ballon inflated to look for blood (blast injury to bladder) and left for now. It may be discontinued in an few hours or the next day or even immediately once the urine is found to not have heamturia.

Dressing changes, pain control and follow-up are essential for the patient. Looking for cellulitis is also important as one worries about necrotizing infections in patients injured in the groin and especially in a war zone.

This patient was very lucky indeed. But do not let the nature of the injury obscure what needs to be done. ABCDE's and so on.

The images show RUG 1 of the prep, RUG 2 of the Foley inserted and the contrast being pushed, and RUG 3 of the column of dye into the bladder and two foreign bodies (fragments) that will be retained. The RUG 3 shows a straight column without any extravasation. Just remember to get obliques and laterals.

DD

[Doc Dutch]

Originally Posted by Red Flag 1

Doc Dutch,

Do you see a reason for soldiers to add an "athletic cup" along with other armor? Granted this soldier would have seen little protection as this played out. Others may see the "cup" as a benefit. Your thoughts kind sir!

This was a lucky Dude!

RF 1

Sir,

I know that troops in the American Revolution and the Civil War had fashioned some groin protection. I am not sure what is out there but I bet someone has looked into this issue as it is very threatening to males in a war zone. I do know there are extenders to the basic body armour but I am not sure what is available for the groin region. I am very aware young men in atheletics here in the US are always cautioned about a "cup protection". However, I am also know that added bulk is uncomfortable and may be disguarded as it slows people down and may be uncomfortable. Young men still come in to our center with trauma from sports injuries having not worn their cup. So, there is always a cost benefit ration to the individual.

As in this case, he knew better not to put the 9 mm in his belt line and chose still to do it. Not sure in his case if it would have made a difference.

DD

[Swank]

Originally Posted by Doc Dutch

Agree with usual priorities. There was some blood loss en route (about a unit of blood but the bleeding stopped by arrival. Subsequent wash-out was necessary but little bleeding was encountered. Did not stitch up the wound and left it open as did not want to trap infection (did give antibiotics). Sphincter tone was normal with rectal examination. No blood was seen at the meatus and keeping careful watch to not cross contaminate, the blood was soaked up and pressure held to the perineal wound with the rectal examination. There was no blood found on rectal exam. The patient was hemodynamically stable at all times.

He was hemodynamically stable, pelvis films will be shown below. We did not need to explore as it turned out because the CT with IV and rectal contrast and delays were negative. We did need a retrograde urethrogram (RUG) however to assure the urethra was okay. An indwelling Foley can be passed only after the RUG and no urologist was needed. The CT helped us in regards to looking at the bone fragments, vascular injuries and soft tissues including the bowel.

The Bobbitt case (replant of the penis) has been repeated many times in the US. Most of the urogenital trauma in war zones are not simple lacerations or simple amputations and are more in line with severe debulking trauma or complete loss of the penis and/or testicles. Blast injuries with the directed force straight into the groin can be devastating and typically nothing to replant and unfortunately just debridement and dressing changes. His outcome is actually favorable in the case.

DD

Fun fact: Bangkok leads the world in penile re-attachment sx. Beware of pissing off your Thai dictionary.

Doc, I'm curious about the specifics of the MOI. Do you happen to know exactly where the pistol was tucked? Was the hammer cocked?

It's SOP on many if not most teams to leave the safety off when carrying the M9. If the hammer was not cocked, the blast would had to have racked the slide to the rear in order for the hammer to fall on the firing pin. I'm not asking to be critical, but to be safe.