GSW to Lower Extremity: PFC Case Discussion 7

Our case discussions are provided to get you, the medic or provider, to think about treatment and logistical issues.  The following case is a ‘simple’ scenario constructed to get you thinking about long term pain control

without the distractions of a more complex case.  Once you read through the scenario, please take the survey at the end so that we can discuss the results in the next podcast on pain control. We have also included links to our previous posts on pharmacology and analgesia so that you can reference them in one place.

We had been running an assistance mission for about 5 months. After months of little action, we started to get complacent. During one of our area recons on the outskirts of our AO, we decided to split the two vehicles up.  Our vehicle would go straight through a small village and the other would go around to the north and would link back up with us couple of miles west of the village. Under cover of afternoon we decided to roll through and see what we could see. We knew that we didn’t really blend in with the locals , but we figured “Speed is security” and we would be gone by the time anyone really realized who we were.

As we drove through the village, I got the feeling that something wasn’t right. Suddenly a soccer ball rolled into the road.  John slowed the truck and I looked over just in time to see a local level his rifle and fire from the hip at us from the alleyway. In the time it took me to scream “DRIVE”, bullets began hitting the truck. I raised my weapon and took well aimed shots at (sprayed) the alley as the driver stepped on the gas and blew through the rest of the village. As we cleared the village, I noticed that there was blood splattered on myself, and Steve began yelling that he had been hit. I yelled at John to radio the other team as I began treating Steve. I found that he had taken a round through the thigh with heavy bleeding. A tourniquet high on the leg thankfully was enough to stop the bleeding, but I knew it was going to be a long, 30-45 min, very bumpy ride back to the safe house.

When we linked back up with the other team, I did my secondary assessment (no airway involvement or other injuries) and began tracking vitals and started thinking about analgesia. Traveling light, I was only carrying a bare bones kit for med supplies including two vials of ketamine and Tylenol for analgesia.  I went with intranasal ketamine 50mg every 20 min as needed. Steve’s blood pressure remained over 110mmHg systolic, so I didn’t bother with the IV until we got back to the safehouse. This knocked his pain down to a tolerable level 3/10, but every rut and bump on this road was followed by an audible moan.  I needed to get back to my clinic.

As we all drove into the compound, I was thinking about the 9-line and MIST report to get Steve out of here quick, but as I looked back from where we came, I saw a very ominous sign, a giant brown cloud engulf the horizon….A sand storm…..perfect.

After radioing in for a MEDEVAC, I was told that no birds could fly due to the sand storm and to “hold tight for the next 24 hrs or so.” I ran back to my clinic to take inventory of what I had for pain control meds.

In my narc box I had:

20 Tabs Percocet (Oxycodone/tylenol)

3 – 5ml vials ketamine 100mg/ml

3 x 2ml vials fentanyl 100mcg/ml

2 x 1ml vials mg hydromorphone 2mg/ml

2 x 1ml carpuject vials morphine 10mg/ml

2 x 1ml carpuject vials naloxone .4mg/ml

1 x 5ml vial Versed 5mg/ml

1 x 5ml vial romazicon 5mg/ml

2 x 20ml vials propofol 10mg/ml

3 x 1ml ampule ephedrine 50mg/ml

I also had:

3 x 1ml ampule epinephrine 1/1000

2 x 1ml Carpuject vials of diphenhydramine 50mg/ml

20 tabs of 4mg Zofran

2 x 1ml ampule Phenergan 50mg/1ml

2 x 50ml vials 2% Lidocaine w/ epi

1 bottle of 100 tabs 325mg Tylenol

Stimuplex + needles

Ultrasound machine and gel

Discussion Questions:

SOMSA 2016 Ketamine and Pharmacology Lab

Scott Weingart from EMCrit on PFC and Ketamine

Part 3 of the Pharm Series… Ketamine and PFC

Part 2 of the Pharm Series… The MSMAID Acronym From Anesthesia Adapted to Prolonged Field Care

Part 1 of the Pharm Series… 12 Principles of Pharmacology