PFC: Gunshot Wound with Tourniquet

[Max D]

source: http://prolongedfieldcare.org/2015/06/11/weekly-pfc-case-discussion-1-gsw-wtq/
Weekly Case Discussion #1: GSW w/TQ

Just as a rehearsal of a tactical operation will prepare the operator to better deal with contingencies, discussing and talking through realistic, hypothetical, medical scenarios will give the medic a good idea to how he might respond should a similar situation arise in real life. We encourage participation in the discussion by all levels of medic, nurse and provider. Constructively thinking through worst-case illness and injuries, through multiple perspectives, will open the eyes of those on the other side of the wire, no matter which side that may be. If you have an idea or concern, throw it out there. Don’t be scared…

Some Ground Rules:

Cases will be intentionally vague.

There is no “right” answer, it’s a discussion.

You will have each patient for 24 to 72 hours.

Plan for the worst-case scenario. Murphy’s Law is in effect.

No crazy CT or MRI studies. You might possibly, maybe, have an ultrasound. You are in an austere environment and have what a medic would bring. If you aren’t familiar, search the site for “PFC Pelican Packing List” for a basic layout. (It’s at the bottom of that page.)

We want to improve morbidity as well as mortality. Imagine the patient is your own family member.

You will likely have to fly with your patient for 8 hours on a “slick” (no med crew or equipment) aircraft. Be sure to consider both patient and equipment preparation.

You have one junior medic and a handful of non-medics as helpers.

Local blood supply and pharmacy are questionable at best. The primitive lab in town has a turn-around of at least 4 hours for the most basic tests.

Feel free to address the “no-evac-possible” scenario.

Scenario # 1: GSW w/TQ

A U.S. service member sustains a GSW to the upper calf when the host nation soldier fails to clear his weapon properly. The soldier had no tourniquet on the range and bled for approximately 5 minutes. With vascular injury to the popliteal artery, the SOF medic can only gain complete hemorrhage control with a well-positioned tourniquet, although the patient has already lost a significant amount of blood. This patient may appear to be an easy TCCC case, but consider how this can spiral out of control…

 

[EKinOR]

OK, I'll bite. First, my training: Wilderness First Responder w/ several re-certs, annual 4 hr training (last 3 years) on TQ application, needle decomp, NPA use. Former USMC Combat Engineer, but pre-TCCC (88-94) and current patrol officer. I've had experience with several major traffic crashes, lots of minor stuff, but not first hand experience treating GSWs or similar.

My first thought is leave the TQ in place since it has stopped the bleeding. Be prepared with a second TQ in case the first fails, to the point of having it in place proximal to the first but not tightened down. Any sign of bleeding gets the second TQ tightened down. If the nature of the wound supports it, pack it with hemostatic gauze as well. Immediately start the ball rolling for evac to a higher level of care. Dress the wound to minimize contamination, but not impact observation for renewed bleeding. Keep the Pt prone, but comfortable (elevate legs slightly if possible), monitor vitals, watch for signs of volumetric shock. Based on the scenario as presented, I'm assuming no ortho injuries.

Anticipated problems: Renewed bleeding potentially leading to cardiac arrest if uncontrolled, infection, pulmonary embolism.

Considerations: Pressure dressing(s)?

 

[Max D]

M: Well positioned tourniquet.
A: In tact, patient maintains. Have airway adjuncts available (NPA)
R: Adequate and normal as far as I can gather. I will be cognizant of increased RR as a sign of symptomatic hypovolemia.
C: Establish an IV for the administration of initial fluid challenges with a target BP of 90-100 systolic. Fluid challenges should be given in moderation with warmed fluid. I would hold off on starting two large bore IV lines right off the bat and dumping a liter of NS into him just because he is asymptomatic at this point and if I start a could lines, they may not last the full 48 hours plus transport. Better to establish a line, have a few additional sites picked out. If the patient is awake and able to protect his own airway, then I'd give him warm sugary fluids (warm Gatoraid or the like). I'm not trained on walking blood banks, so I wouldn't attempt a transfusion. I probably wouldn't have a GHC with blood products, so 1:1:1 transfusion isn't possible.
H: Isolate patient from convective cooling, add active warming such as ready heat, give heated fluids if possible (hand warmers taped to tubing coil if necessary)

P: Consider OTFC is BP is stable. Consider Ketamine at the opioid sparing dose if available.
A: Depending on what I have available, I can give him (in order of preference) Moxifloxacin 400mg every 24 hours by mouth, or I can give him a shot of Ertapenem 1g, or I can give him 2g of Cefotetan every 12 hours.
W: Once pain control has been achieved, I can irrigate, pack and dress the leg wound.
S: Unless there is damage to the bone, splinting won't be a concern at this point. Because of his acute hypovolemia, I'd keep him laying down or in semi-fowlers as tolerated.

R: I would consider reducing the tourniquet at around the 4-hour mark, but would be skeptical and cautious considering the arterial inclusion. If reduction fails, a fresh deliberate tourniquet will be placed.
A: No airway care is expected, but I will have airway nearby.
V: No artificial ventilation is expected, but I will have a BVM with PEEP valve nearby.
I: Depending on my commo capabilities, I would start a telemedicine consult with my surgeon. I would run my decision to reduce the tourniquet by the surgeon before the attempt.
N: Food and drink as tolerated, no catheter required although patient will need help with urination and defecation.
E: Treat for hypothermia, protect from sun exposure, prep for transport to include ears and eyes