Page 16 - Journal of Special Operations Medicine - Fall 2014

After the application of that first tourniquet, I Figure 1 Side-by-side C-A-T s on the right upper extremity.
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removed the belt and decided to place another
tourniquet as high up on what was left of his
limb just to be safe. The first tourniquet was in
place and secured in less than a minute on my
arrival on scene.

Because the subject was naked, the officer quickly
checked for other major injuries and did not find any
other injury than road rash.

Charlotte Fire Department (CFD), the county basic life
support (BLS) service, arrived on scene at 1542. CFD
prepped the patient for transfer, including implementing
basic hypothermia prevention. Charlotte-Mecklenburg
emergency medical services (EMS) (MEDIC) arrived on
scene at 1545. On arrival of EMS personnel, the patient
was expeditiously loaded into ambulance, the arm was
located in the woods, and patient was transported to
the hospital for definitive care. Prehospital vital signs
reported a highest heart rate of 138 beats/min, lowest
blood pressure of 200/110mmHg, and best Glasgow
Coma Scale (GCS) score of 15.
theater at 1635 hours (Figure 2). In the operating room,
Emergency Department and Hospital Course the axillary artery was identified and a vascular clamp
On arrival in the emergency department (ED) at 1559 was applied. Given the limited size of the upper extremity
hours, patient was noted to have a traumatic amputa- stump, the orthopedic team left the C-A-T in place until
tion of the right arm at the proximal humerus as well as proximal arterial vascular control was achieved. Further
multiple abrasions to the upper and lower extremities bi- dissection was undertaken to suture ligate the axillary
laterally. The Combat Application Tourniquet (C-A-T ; artery more proximally. Additional dissection was per-
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North American Rescue, http://www.narescue.com/) formed to identify additional neurovascular structures in
was in place with no active hemorrhage (Figure 1). Ini- the exposed axilla, specifically terminal branches of the
tial ED vital signs were notable for heart rate of 126 radial, ulnar, and median nerves for possible myoelectric
beats/min, blood pressure of 97/55mmHg, and GCS above-elbow prosthesis. The wound was irrigated and un-
score of 15 (1600 hours). The patient had a negative derwent sharp debridement of grossly contaminated and
focused assessment with sonography for trauma exam, nonviable tissue, and muscle was loosely approximated
and no other obvious injuries were identified. Initial over exposed bone. The patient remained in the hospital
labs were notable for an initial hemoglobin level of 12.6 for 24 days, undergoing additional treatment and ther-
g/dL and lactate level of 14.4 mmol/ L. apy. He was discharged with daily dressing changes to an
inpatient psychiatric facility to undergo additional man-
Based on the patient’s tachycardia, relative hypotension, agement of his psychiatric conditions, as well as follow-
and elevated lactate level, the trauma team initiated com- up with orthopedics in the outpatient clinic.
ponent blood therapy treatment with the administration
of 2 units of packed red blood cells in the trauma bay
as well as antibiotic prophylaxis with 2g of cephazo- Discussion
lin ( Ancef ). The trauma surgery and orthopedic sur- This case reports highlights three critical findings. First,
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gery teams took the patient emergently to the operating LEOs are frequently the first on scene for major trauma

Figure 2 Patient tourniquet timeline.

Total Tourniquet Time: 80 Minutes

8 Journal of Special Operations Medicine Volume 14, Edition 3/Fall 2014