Page 21 - JSOM Spring 2018

breathing. He was in pain, but it was difficult to determine distal extremities, making peripheral pulses and pulse oxim-
whether this was due to the GSWs or the tourniquet. etry difficult to assess. However, he did have a strong carotid
pulse with a rate that varied between the 70s and 90s.
The Ground Force placed the patient on a litter with two Ready
Heat blankets (TechTrade, http://www.ready-heat.com/) and In addition to the hypothermia prevention device and use of
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an older version Hypothermia Prevention and Management the fluid warmer, the physician placed Ready Heat panels
Kit (North American Rescue, https://www.narescue.com). The around the patient to prevent hypothermia. The time of flight
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patient received 1g of ertapenem sodium intramuscularly in was approximately 8 minutes, with no significant change in
his left deltoid. An 18-gauge saline-lock intravenous (IV) cath- patient status during this initial transport.
eter was placed in the patient’s left antecubital fossa, and 1g of
tranexamic acid was administered via slow IV push. Because of The TACEVAC team transferred the casualty to a tactical sur-
the abdominal/junctional GSW and absent radial pulses, Medics gical element positioned near the target. Because the patient
determined the casualty was a candidate for WB. They retrieved had a soft abdomen and a strong pulse with an encouraging
1 unit of LTOWB from the Golden Minute Container (Trib- rate, the team triaged a second patient as more critically injured
™
alco, http://www.div-6.com) and prepared an administration and this patient received immediate surgical intervention. The
set that contained a standard micron filter. Because the Golden first patient was taken to the resuscitation area for continued
Minute Container maintains WB between 1°C (33.8°F) and 6°C evaluation and care. He remained sedated but responsive, and
(42.8°F) for up to 24 hours, a Belmont—buddy lite (Belmont his systolic BP (mmHg) was in the 90s and diastolic BP in the
6
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Instrument Corp, http://www.belmontinstrument.com) was 60s. Initial surgical assessment confirmed the injuries previ-
prepared to heat the WB to a more desirable temperature. ously noted, including likely through-and-through GSW to the
right shoulder with likely fracture of the clavicle/humerus, a
Once the WB was ready, medical personnel administered it GSW to the left lower quadrant of the abdomen, and multiple
as quickly as the administration set would allow. There were hemostatic shrapnel injuries to bilateral lower extremities.
no immediate adverse reactions as the transfusion began. The
patient continued to moan in pain and was somewhat non- The physician placed monitors on the patient and noted he had
compliant because of the language barrier and/or uncertain normal sinus rhythm in the 70s, BP readings that varied be-
disposition on the litter. Thus, Medics gave ketamine. Ket- tween 90 and 130s systolic and 60–90s diastolic (mmHg), and
amine 60mg and midazolam 0.6mg were administered intra- a pulse oximetry monitor that was not registering, presumably
muscularly in the patient’s lateral right thigh. Shortly after due to continued cold distal extremities. Reassessment revealed
administration of the medications, the patient relaxed, was the following: a small amount of bleeding beneath the tourni-
more compliant, and remained on the litter. quet, intact airway, unlabored respirations with equal rise and
fall of the chest, occlusive dressings in place, hemostatic lower-
After these interventions, Medics recorded the patient’s vital extremity shrapnel wounds, and that the patient remained in the
signs again, noting a continued absence of radial and brachial hypothermia prevention device with Ready Heat blankets. Fur-
pulses, and cool dry skin. Attempts to take a manual blood ther examination revealed an atraumatic head and neck with no
pressure (BP) were not successful. The patient’s carotid pulse bony abnormalities, a soft abdomen, and stable pelvis; extrem-
remained strong and was now 70–75 bpm. Administration of ity examination as noted above with cool extremities; a rectal
WB continued through tactical evacuation (TACEVAC) air- examination that revealed no tone and the presence of gross
craft landing and handoff. blood. While the patient was breathing spontaneously and pro-
tecting his airway, the physician noted decreased muscular tone
TACEVAC Care Team 1 of lower extremities and only spontaneous movement of the up-
The TACEVAC team received turnover of the patient on the per extremities and neck, concerning for a spinal cord injury.
ramp of the aircraft, moved him onto an Absorbent Patient
Litter System Thermal Guard (Paperpak Industries, http:// Because the patient had reassuring vital signs and a soft/be-
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paperpakapls.com/) hypothermia prevention device and im- nign abdomen, the patient remained in the resuscitation area
mediately reassessed him. The health care provider noted the as the surgical team cared for the second patient who was tri-
patient would open his eyes periodically and had the distant aged as urgent surgical. After approximately 40 minutes of
gaze commonly seen in those who have received ketamine. monitoring, the first patient began to have some mild pelvic/
lower abdominal distention and his BP began trending lower,
The patient had a patent IV catheter in the left antecubital consistently in the 90s/60s mmHg. While the patient’s pulse re-
fossa, and he had received approximately one-half of the unit mained in the range of 70–90 bpm, the surgical team decided
of LTOWB through a buddy lite fluid warmer. The team evalu- to move the patient to the surgical table for continued moni-
ated the patient for active bleeding and noted two dislodged toring and ready access if there was further decompensation.
chest seals on the right shoulder that no longer covered the
wounds. They noted a small amount of blood from the wounds Immediately after transferring the patient to the surgical table,
on the right lateral shoulder and trapezius area, which they cov- the surgeon placed a right femoral central line and the nurse
ered with occlusive dressings. The remainder of the evaluation anesthetist provided additional sedation and pain control.
revealed no active bleeding from multiple shrapnel wounds in Through the central line, he received 6 units of group O- positive
bilateral lower extremities, nor was there active bleeding from packed red blood cells (PRBCs), 4 units of thawed fresh-frozen
the wound beneath the SAM Junctional Tourniquet Target plasma (FFP), and a second dose of tranexamic acid.
Compression Device in place on the left lower quadrant.
With a continued sporadic heart rate, concerning BP changes,
The patient’s airway was intact and there was bilateral equal and increased bleeding and distention from the abdominal
rise and fall of the chest. The patient was cold and had cold GSW, the patient was declared an emergent surgical patient.

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