Case Discussion #1: GSW w/TQ
Just as a rehearsal of a tactical operation will prepare the operator to better deal with contingencies, discussing and talking through realistic, hypothetical, medical scenarios will give the medic a good idea to how he might respond should a similar situation arise in real life. We encourage participation in the discussion by all levels of medic, nurse and provider. Constructively thinking through worst-case illness and injuries, through multiple perspectives, will open the eyes of those on the other side of the wire, no matter which side that may be. If you have an idea or concern, throw it out there. Don’t be scared…
Some Ground Rules:
Cases will be intentionally vague.
There is no “right” answer, it’s a discussion.
You will have each patient for 24 to 72 hours.
Plan for the worst-case scenario. Murphy’s Law is in effect.
No crazy CT or MRI studies. You might possibly, maybe, have an ultrasound. You are in an austere environment and have what a medic would bring. If you aren’t familiar, search the site for “PFC Pelican Packing List” for a basic layout. (It’s at the bottom of that page.)
We want to improve morbidity as well as mortality. Imagine the patient is your own family member.
You will likely have to fly with your patient for 8 hours on a “slick” (no med crew or equipment) aircraft. Be sure to consider both patient and equipment preparation.
You have one junior medic and a handful of non-medics as helpers.
Local blood supply and pharmacy are questionable at best. The primitive lab in town has a turn-around of at least 4 hours for the most basic tests.
Feel free to address the “no-evac-possible” scenario.
Scenario # 1: GSW w/TQ
A U.S. service member sustains a GSW to the upper calf when the host nation soldier fails to clear his weapon properly. The soldier had no tourniquet on the range and bled for approximately 5 minutes. With vascular injury to the popliteal artery, the SOF medic can only gain complete hemorrhage control with a well-positioned tourniquet, although the patient has already lost a significant amount of blood. This patient may appear to be an easy TCCC case, but consider how this can spiral out of control…
I’ll get the ball rolling with a few questions:
What will be used for pain control?
What will be done for fluid resuscitation? Hextend? FWB? LR?
What are the trigger criteria for a fresh whole blood transfusion?
Would a Foley or Condom catheter be warranted?
How will the urine output be measured?
At what point will the tourniquet be converted?
What if it can’t be?
What are the consequences of having a tourniquet on for 24 – 72 hours?
Paul, in answer to your questions above these are my thought ranging from initial to long term.
Initial treatment
Pain control: Ketamine as a stand alone for control pain but not to deep sedation or an anesthetic plane. I’d prefer to go intranasal so I get a longer half life and I don’t have to constantly re-stick him if I was to go IM. I know everyone’s on the Versed/ Ketamine combo kick but for me if I can avoid dealing with a respiratory issue and I’m getting good pain tolerance why make it more confusing.
Resuscitation: Not having a set of vitals I would go big early and go with whole blood (US member) depending on the safety of our current area of operations and potential for another injury. Yeah I could get away with Hextend or LR potentially but it would only be a volume replacement adjunct and nothing else. This ties into the TQ conversion but I would maintain BP around 90 systolic if he seemed stable after conversion and slowly increase to something more normal if I felt he had a stable clot. I want to reiterate the focus on hypotensive resuscitation until he deems himself stable.
Triggers for FWB are; massive blood loss, and non-compressible bleeding
Foley or Condom: Foley, reason being he’s not getting up anytime soon, I’m not well versed in the condom catheter and I will get a more accurate reading with a Foley.
Prolonged Care
Pain control: Switch to an opioid for longer pain management or go with a bag of Ketamine and Versed for sedation. I’m leaning towards the opioid, yeah hanging bag is potentially easier but gives a false sense of security in regards to pain management and I’m more comfortable with the opioid route. Talk to someone way smarter then me and see if a regional block would be a good option.
Urine Output: Measured hourly with a goal of 0.5 cc/kg/hr on low end or 1 cc/kg/hr on high end after a quick call to higher medical care provider for his opinion.
TQ conversion: I’m going to be sitting on this guy for a decent amount of time so I would attempt conversion within the first hour. I’d worry about the conversion prior to worrying about output because I would be afraid to over resuscitate and potentially blow a clot.
Conversion Not Possible: Seek higher medical authority as to pros and cons of leaving the TQ in place for entire CASEVAC vice discussing a possible amputation to salvage viable tissue.
Consequence: A tourniquet on place for that long would leave a distal limb useless.
Other thoughts: I’d push TXA because why not, yeah potentially it is a compressible bleed but I’d rather give everything I got on this one patient just in case. Yes he has a TQ in place which would make me ask higher medical authority do I wait to push TXA until I remove the TQ or is it still beneficial prior. Reason I’m asking is I’m trying to affect the area of hemorrhage and he has a TQ on will it do anything?
I would see if the patient tolerated oral hydration vice I’v fluids hence the reason for pain management and not deep sedation.
Thanks for such a comprehensive response. You bring up more issues as this discussion was meant to. Some of them we have already recognized and put out our official position papers which can be found elsewhere on the site. These can’t possibly cover everything a medic will encounter which is why we discuss and study the literature available and consult the big brains.
My initial reaction is that TXA is not without other potentially adverse events such as DVT and PE. Here is Scott Weingart’s EMCrit Page with everything TXA including the CRASH2 study. http://emcrit.org/?s=TXA
Regional anesthesia is a powerful tool which is now taught and practiced at the schoolhouse. The reference book is the Military Advanced Regional Anesthesia and Analgesia (MARAA). Even better if you can get the nerve stimulator and get some practice on it.
I have talked to one surgeon about the amputation issue recently and his opinion seems to be that amputation should be reserved for when all else fails and the limb is necrotic and gangrenous. That being said, it wouldn’t hurt to start getting all of your equipment ready and sterile ahead of time since it is probably at the bottom of multiple tuff boxes next to someone’s spare mags and protein powder. How effective can limb cooling be?
If you have access, login to the http://www.learn.Jsomtc.org LMS website and watch the refresher videos in between taking vitals and your other nursing care tasks.
I threw condom cath out there after talking to an EM Physician who suggested it. Maybe serial straight caths or suprapubic bladder taps would be warranted depending on other circumstances and availability.
I will be very interested to hear some other opinions on some of the issues identified.
The previous comment was excellent, well thought out, and well presented. I would add, early broad spectrum antibiotics to my early priorities of management. I would agree with FWB transfusion, and proper damage control resuscitation, allow for permissive hypotension and clot formation. I would consider conversion of the TQ after appropriate FWB resuscitation, proper urine output / kidney perfusion and patient remains hemodynamically stable and vitals trending that way. Either with proper wound packing, and possibly IT clamp use. If removal of TQ is being explored, have appropriate FWB service member available to donate. Depending on length of time TQ in place have Calcium, available for cardiac protection from post reperfusion injury / K+ . As well with Bicarb, ventolin – because probably insulin isn’t available so insulin + dextrose isn’t an option for shifting K+. Similar to crush injury and the associated death due to cellular toxins returning to the heart post removal of the large object preventing blood flow. Now, I inderstand the calf isn’t a large area, so to draw a straight line between crush injury and TQ removal isn’t simple – but it should be considered, and prep for. IMO. Great discussion.