Page 113 - Journal of Special Operations Medicine - Fall 2016

needle was found to be nonfunctional. Central venous Role III Care
access was immediately obtained by placing a right sub- The casualty remained hemodynamically stable through
clavian 8.5F introducer sheath. The patient received a his arrival at Role III. He underwent chest washout,
combination of IV fentanyl, ketamine, and midazolam definitive chest closure, and a negative exploratory
for pain management and anxiolysis. An infusion of laparotomy done for suspicion of hollow viscus injury
thawed plasma and PRBCs was simultaneously started (Figure 2). He was awarded his Purple Heart while in-
via introducer sheath through a portable fluid warmer. tubated in the intensive care unit. He was transferred,
intubated, by a Critical Care Air Transport Team to a
Repeated focused abdominal sonography for trauma Role IV facility.
revealed no pericardial fluid, although the examina-
tion was technically limited by artifact. Lung sliding Figure 2 The casualty, still intubated, meets one of his
was unable to be appreciated bilaterally. The abdominal Special Operations medics at Role III (photo used with
portion of the examination was unremarkable. Under permission of the casualty. Names have been withheld and
local anesthesia, a right-sided tube thoracostomy was the photo redacted for operational security).
placed with a rush of air, relief of a right tension pneu-
mothorax, and 400mL of bloody output. The casualty’s
hemodynamics remained poor. A left-sided tube thora-
costomy was placed under local anesthesia with a rush
of air and 2L of bloody output. His hemodynamics did
not improve and the team postured for surgical explo-
ration of the left hemithorax. Preparations were made
for immediate surgical access to the left thorax because
cardiopulmonary arrest was anticipated with induction
of anesthesia.

Fentanyl, ketamine, midazolam, and succinylcholine
were administered to facilitate a rapid sequence induc-
tion and subsequent successful endotracheal intuba-
tion. During induction, the casualty arrested and a left Role IV/V Care
anterolateral thoracotomy was performed. Because of Upon arrival, the casualty was re-evaluated and trans-
darkness and the below-freezing conditions, surgical ported to the operating room for washout of his wounds.
visualization was difficult as a result of sudden con- He was extubated and transferred to care within the
densation of the cold air entering the surgical field. A United States. After a brief hospital stay and intensive
massive hemothorax containing clot and blood was physical therapy at a rehabilitation unit, he was released
evacuated from the pleural space. A pericardiotomy was home in good condition.
performed and an empty, but uninjured, heart was de-
livered. A gunshot wound to the proximal pulmonary Epilogue
parenchyma was identified and hemostasis was tempo-
rarily obtained with a finger and transitioned to a pair This case represents a success of translation of evidenced-
of vascular clamps. The casualty’s heart was massaged, based medicine to the far-forward tactical environment.
blood products were administered, and, with some me- This casualty received early FDP, early pharmacologic
chanical manipulation, the heart resumed organized antifibrinolysis, high-ratio transfusions, and early, far-
electrical activity with return of spontaneous circula- forward expeditionary damage-control surgery. It is also
tion. The total cardiopulmonary arrest time was ap- notable that this casualty did not receive any crystalloid
proximately 7 minutes. The pulmonary vascular injury therapy during his initial several hours of care. This rep-
was carefully repaired with suture and clamps removed. resents excellent execution of tactical damage- control
The blood pressure was 125/88mmHg after an addi- resuscitation and surgery as a result of exceptional
tional unit of plasma and PRBCs. A temporary chest training of tactical military medical personnel (Table 1).
closure was placed.
The global projection of US Military power remains a
Subsequently, the casualty’s left chest was re-explored requirement in these uncertain times. Force projection
and venous bleeding from the posterior chest wall in- of medical capabilities is an additional challenge in re-
jury was controlled with packing. The temporary chest mote military operations and is necessary to salvage Op-
closure was reapplied. The casualty underwent an addi- erators from life-threatening combat wounds. This case
tional long movement by fixed-wing aircraft and arrived represents successful execution of an aggressive, tacti-
at a Role III facility. cally forward, military medical posture.

Prehospital Traumatic Arrest 95