Page 22 - JSOM Spring 2018

He underwent rapid-sequence induction with intubation, and a Cardiac ultrasound revealed poor ventricular filling and glob-
midline open laparotomy was initiated. The surgeon opened the ally poor cardiac motion. The patient continued to have blood
linea alba to expose the preperitoneal fat but did not violate the welling up from his pelvis. The surgeon continued control of
peritoneum. He observed the peritoneum to be bulging with air the aorta with a clamp just above the bifurcation and repacked
and blood. The fascia was opened from the xiphoid to the pu- the pelvis. With these interventions in place, blood no longer
bis, and the surgeon bluntly entered the peritoneal cavity with a appeared to be welling up. The abdomen was then dressed,
large rush of dark blood (approximately 2–3L) and no obvious additional warming blankets were placed on the patient, and
clot. The bleeding seemed to emanate most from the left pelvis. the patient was continuously monitored. The last set of vital
The surgeon and team physician assistant worked in concert to signs obtained by this team was a heart rate in the 120s and a
quickly pack the left paracolic gutter, pelvis, and right paracolic BP of 90/56mmHg.
gutter, which appeared to control the hemorrhage.
Role 3 Care
The surgeon suspected that the patient had a pelvic venous Within minutes of arriving at the Role 3 facility, the patient
injury (perhaps lower inferior vena cava or right iliac vein), lost vital signs. In the trauma bay, the Role 3 trauma team per-
though exploration to prove this was not prudent because formed a resuscitative thoracotomy, placed a left subclavian
damage control was the preferred option. The surgeon covered central line, and administered multiple units of PRBCs and
the bowel with laparotomy pads and closed the abdomen with blood products. The trauma surgeon noted no thoracic inju-
a loban temporary abdominal closure. During the surgery, the ries but observed the heart was empty and had no movement.
team used additional Ready Heat devices, warmed blankets, Open cardiac massage ensued and intracardiac epinephrine
and an enFlow fluid warmer (GE Healthcare, http://www3 was administered twice. After approximately 15 minutes of
®
.gehealthcare.com) to prevent further heat loss. After the surgi- aggressive resuscitation attempt, the patient continued to have
cal procedure, the casualty was tachycardic (120+ bpm), with no vital signs. The team terminated efforts and pronounced
systolic BP varying from the 70s to 90s mmHg. The laparot- the patient dead.
omy pads did not appear saturated (i.e., white was still visible,
suggesting hemorrhage control). Shortly thereafter, the team Conclusion
prepared the casualty for transfer to another tactical surgical
element at an undisclosed airfield in Afghanistan. The primary This is a case in which a casualty received prehospital group
team handed off the casualty in critical condition with a secure LTOWB via the ROLO protocol and did not appear to have
airway and labile vital signs. any adverse reactions. Although this casualty eventually would
succumb to his wounds, he did survive two major surgeries
TACEVAC Care Team 2 and a lengthy evacuation to the Role 3 facility. Because this
Team 1 transferred care of the patient to the second team with patient likely had a significant vascular injury, the WB therapy
known concern for ongoing intra-abdominal bleeding as well probably contributed to his initial triage presentation as more
as a possible spinal injury. The patient initially had a Glasgow stable than his injury would have suggested otherwise. Provid-
Coma Scale score of 3T, with labile heart rate and a BP that ers must take this potential change in clinical presentation into
was initially difficult to obtain. The carotid pulse was weakly consideration because the use of WB could skew one’s clinical
palpable with a rate in the 120s. Endotracheal tube placement judgment and potentially inappropriately delay surgical inter-
was confirmed, with good air movement and bilateral rise and vention. In addition, there appeared to be no adverse reactions
fall of the chest noted, but percent oxygen saturation readings to LTOWB during administration. The ability to administer
remained in the mid 80s. WB within minutes of injury has a high likelihood of preserv-
ing life that would have previously been lost on the battlefield.
In the short time (less than 15 minutes) between receiving the
patient and departure, the abdominal laparotomy pads be- Disclosures
came saturated and the abdomen became more distended. In The authors have nothing to disclose.
addition, the patient demonstrated an increase in his tachy-
cardia to a rate in the 140s, a worsening of his hypotension to Author Contributions
approximately 70/50mmHg, and an end-tidal carbon dioxide All authors approved the final version of the manuscript.
reading in the teens.
References
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abdominal hemorrhage, the abdomen was re-entered. The to anti-A and anti-B caused by the transfusion of blood or blood
patient received 50mg of vecuronium and 1 ampule of cal- components containing ABO-incompatible plasma. Transfusion.
2013;53(suppl 1):114S–123S.
cium chloride. The surgeon obtained supraceliac control of the 2. Kendrick DB. Blood program in World War II. 1964. http://history
aorta manually and found the aorta to be relatively flaccid .amedd.army.mil/booksdocs/wwii/blood/default.htm. Accessed 1 June
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cern for the possibility of proximal venous injury and concern 3. Committee on Tactical Combat Casualty Care. Tactical Combat
that the right femoral central line was ineffective, so the nurse Casualty Care Guidelines for Medical Personnel. 11 November
anesthetist placed a second peripheral IV catheter. In approxi- 2015.
mately 30 minutes, the patient received 5 units of O-positive 4. Fisher AD, Miles EA, Cap AP, et al. Tactical damage control resus-
citation. Mil Med. 2015;180:869–875.
PRBCs and 3 units of FFP, for a total of 10 units PRBCs and 5. Strandenes G, Berseus O, Cap AP, et al. Low titer group O whole
6 units of FFP. The patient persistently demonstrated systolic blood in emergency situations. Shock. 2014;41(suppl 1):70–75.
BP readings in the 70s–80s mmHg despite proximal aortic 6. Tribalco. Golden Minute Container. http://www.div-6.com/golden
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an appropriate response in BP was observed.

18 | JSOM Volume 18, Edition 1/Spring 2018