Page 112 - Journal of Special Operations Medicine - Fall 2016

Figure 1 Freeze-dried plasma and tranexamic acid were status was significantly improved and return of radial
administered to the casualty. pulse was noted.

The casualty was placed on a litter with a hypothermia
prevention and management kit consisting of a Mylar
foil hypothermia blanket with chemical warming packs.
A short but difficult movement ensued, with continual
casualty reassessments. Due to difficulties with the litter
on the terrain, the casualty ambulated himself the last
100m of this difficult movement over very rocky ground.

Tactical Evacuation Care
At the conclusion of the movement, the casualty was
reevaluated by additional medical personnel. He was
displaying signs of shock but was hyperalert and com-
The casualty’s chest wall was then assessed for injuries plaining of shortness of breath, which worsened when
because he now reported difficulty breathing. The tho- he was in the supine position. He remained sitting up-
rax was exposed, and while palpating his chest, gun- right while further evaluation was performed. All pre-
shot wounds to his right high anterior chest, left high viously identified wounds were reevaluated. A small,
anterior chest, and a wound over his right scapula were portable pulse oximeter was demonstrating a heart rate
discovered. Upon identifying each wound, vented chest of 130 beats per minute (bpm) and an oxygen saturation
seals were placed over each. The wound over the right of 85%. Palpation of the radial artery revealed a thready
scapula presented with a significant amount of bleeding, pulse. The respiratory rate was 30 breaths per minute
so the wound was packed with an advanced topical he- and his skin was cool and clammy. His IV access was
mostatic dressing before a vented chest seal was placed lost during initial casualty movement and a second at-
over it. tempt at placement failed. A sternal intraosseous needle
was successfully placed. Packed red blood cells (PRBCs),
Based on the clinical impression of evolving shortness of under manual pressure, were infused in line through a
breath and increased respiratory rate, multiple 14-gauge portable fluid warmer. The bilateral pleural spaces were
angiocatheters were placed through the chest wall bi- decompressed again with 14-gauge angiocatheters, re-
laterally with rushes of air, confirming bilateral tension sulting in subjective improvement of dyspnea, although
pneumothoraces. In total, seven angiocatheters were his oxygen saturation continued to deteriorate to 70%.
used to serially and repeatedly decompress the chest Diagnostic ultrasonography was performed, which re-
prior to further evacuation. With each angiocatheter vealed absence of free fluid in the abdomen and peri-
puncture administered, the casualty stated he felt a great cardial spaces, although fluid was noted in both pleural
improvement in his mechanics of breathing. The casual- spaces. Absence of lung sliding was noted. The patient
ty’s position of comfort was being seated upright, so he continued to deny pain and was communicative.
was maintained in that position the entire time care was
rendered. His initial respiratory rate was 30 breaths per The casualty quickly arrived at a tactical surgical ele-
minute, and improved with each needle decompression. ment positioned near the target. He appeared ashen,
obviously hypothermic, hypotensive, tachycardic, and
Approximately 5 minutes into care, the casualty be- tachypneic. He was intermittently communicative, fol-
came very lethargic and difficult to arouse. This repre- lowed some commands, and could move all four limbs.
sented a significant change from his initial presentation Total exposure resulted in identification and careful ana-
and he appeared on the verge of losing consciousness. tomic categorization of concerning penetrating wounds
His radial pulse was absent, and only a carotid pulse to (1) the manubrium just left of midline and inferior to
could be appreciated. He had cool and clammy skin. An the sternal notch, (2) the right anterior shoulder over
18-gauge saline lock was obtained in his left antecubital the glenoid fossa, (3) to the posterior thorax just right
fossa. One gram of tranexamic acid was pushed with a of midline in the third thoracic interspace, and (4) to
5mL syringe over 2 minutes. The FDP was then ready the left lateral thorax in the posterior axillary line at the
to administer, but an equipment malfunction occurred fifth interspace.
such that the filtered line in the kit would not effectively
draw the FDP from the glass vial. A solution was field- The initial blood pressure obtained was 85/50mmHg,
improvised, and a 60mL syringe with a filter needle was heart rate was 135 bpm, and respiratory rate was 40
used to draw and slow push the FDP from the vial into breaths per minute. During casualty movements, all IV
the casualty. Once the FDP was administered, his mental access was lost and the previously placed intraosseous

94 Journal of Special Operations Medicine Volume 15, Edition 3/Fall 2016