Page 107 - 2022 Spring JSOM

Medication data included drug and dose for induction, paral- performed using an unknown induction agent and succinyl-
ysis, and vasopressor support. The volume in units of blood choline at unrecorded doses. No blood products were given
products given pre-intubation and within 24 hours of injury prior to intubation. Initial postintubation vitals recorded in-
was collected. In total, 153 critically injured patients met these cluded a SBP of 68, DBP of 36, HR of 160, with unknown RR,
criteria. Of these, seven cases were identified that experienced and SaO . Shortly after repeat vitals were taken, the patient
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PA within 10 minutes of RSI for intubation. suffered postintubation PA. A left lateral thoracotomy was
performed and subsequently extended for a bilateral exposure.
The Marine was autotransfused 1L of whole blood and 2L of
Case Presentation
crystalloid. After receiving a total of 4 U of PRBCs and after
Case 1 surgical efforts to achieve hemostasis were unsuccessful due to
A 29-year-old US Marine presented to a role 2 facility in Iraq disrupted left subclavian vasculature, the Marine passed away.
after sustaining multiple extremity injuries from an improvised
explosive device (IED). The transport modality was not re- Case 4
corded. A physical exam revealed an open skull fracture, mul- A 22-year-old US Marine presented to a role 2 facility in Af-
tiple facial lacerations, and multiple penetrating injuries to the ghanistan via air evacuation after sustaining a gunshot wound
right upper and right lower extremities. The patient arrived to the chest. The physical exam revealed a single gunshot
with tourniquets applied to the right upper and right lower wound to the right anterior chest covered by an occlusive
extremities. Initial vitals were listed as a SBP of 88, diastolic dressing. The initial vital signs were not recorded and GCS
blood pressure (DBP) was not recorded, HR of 160, respira- score was 10. Bilateral needle decompressions were performed
tory rate (RR) of 24, and oxygen saturation (SaO ) of 100%. followed by bilateral chest tubes. Approximately 800mL of
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Initial GCS score was 6. The patient had a shock index (HR/ blood output was observed from the left chest tube and 2L
SBP) of 1.8. A nasal pharyngeal airway (NPA) was placed and of blood was observed from right chest tube. Central venous
a left subclavian central access was established. RSI was per- access was established at an unrecorded site. The patient was
formed 10 minutes after arrival without recorded induction or intubated 2 minutes after arrival using 8mg of etomidate and
paralytic agent. Immediately following RSI the patient entered 140mg of succinylcholine, and then suffered cardiac arrest. No
PA. A left-sided thoracotomy with clamping of the aorta was blood products were given prior to intubation. After entering
performed with subsequent return of spontaneous circulation PA, a left-sided thoracotomy was performed. The left lateral
(ROSC). No blood products were given prior to intubation. A thoracotomy was performed and an injury to the myocardium
total of 10 units (U) of packed red blood cells (PRBCs), 6 U was discovered. The myocardial laceration was successfully
of fresh frozen plasma (FFP), 0 U platelets (PLT), 3 U of fresh approximated with interrupted sutures. During the prolonged
whole blood (FWB), and 0 U of cryoprecipitate (CRYO) were arrest, the Marine received lidocaine, epinephrine, vasopres-
given within 24 hours of injury. The patient died within 24 sin, atropine, and defibrillation. A total of 10 U of PRBC, 1 U
hours of his injuries. of FFP, and 5 U FWB were given over 24 hours. The patient
underwent damage control surgery but died within 24 hours
Case 2 of injury.
A 23-year-old US Marine presented to a role 2 facility in Iraq
after sustaining an IED blast. The transport modality was not Case 5
recorded. Physical exam revealed bilateral above the knee A 26-year-old US Soldier presented to a role 3 facility in Af-
amputations, a large left upper extremity laceration without ghanistan after sustaining injuries from an IED blast. The
amputation, and a penetrating abdominal injury. The Marine transport modality was not recorded. The physical exam was
arrived with bilateral lower extremity tourniquets in place. documented as multiple extremity amputations and a head in-
Initial vital signs were SBP of 90, DBP of 60, HR of 140, RR of jury. Chart description of injuries was particularly limited in
22, and SaO of 90%. The patient had a shock index of 1.55. this case. Vitals preceding RSI include a SBP of 69, DBP of 47,
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Initial GCS score was not recorded. A dose of 5mg of mor- HR of 140, RR of 30, SaO of 99%, and GCS score of 15. The
2
phine was administered for pain control. RSI was performed patient had an initial shock index of 2.02. RSI was performed
16 minutes after arrival using etomidate and succinylcholine 19 minutes after arrival using 30mg of ketamine, 10mg of eto-
at unrecorded doses. The patient suffered postintubation PA. midate, and 100mg of succinylcholine. Initial postintubation
No blood products were given prior to intubation. A total of vital signs were SBP of 77, DBP of 44, HR of 129, and SaO of
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33 U of PRBCs, 8 U of FFP, 3 U of PLT, 36 U of FWB, and 100%. PA occurred shortly after the repeat set of vitals. Trans-
1 U of CRYO were given within 24 hours of the injury. The fusion of one unit of pRBC was started prior to intubation. A
Marine underwent damage control surgery and survived past total of 26 U PRBC, 27 U of FFP, 2 U PLT, and 6 U CRYO
30 days. were given over 24 hours. The patient underwent damage con-
trol surgery but did not survive past 30 days after the injury.
Case 3
A 20-year-old US Marine presented to a role 2 facility in Iraq Case 6
via US Marine Corps casualty evacuation after sustaining mul- A 25-year-old US Marine presented to a role 2 facility in Af-
tiple gunshot wounds. Physical exam revealed wounds to the ghanistan via air ambulance after sustaining injuries related to
left upper chest and right thorax. Initial vital signs were a SBP an IED blast. The Marine arrived with bilateral lower extrem-
of 108, DBP of 56, HR of 156, RR not recorded, and SaO ity amputations with bilateral tourniquets in place. Physical
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of 100%. The patient had a shock index of 1.44. Initial GCS exam revealed weak respirations, right arm and elbow avul-
score was 15. Needle decompression to the left anterior chest sions, a left elbow laceration, an avulsed penis, and multiple
wall was performed before arrival. A left chest tube was placed shrapnel wounds to the right buttock. Initial GCS score was
with an initial output of 2L of blood. Approximately 45 min- 13. Vital signs preceding RSI were SBP of 61, DBP of 41, HR
utes after arrival, the Marine became hypotensive and RSI was of 93, and SaO were not recorded. The patient had an initial
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