Clinical Case 018: Life and limb (not life OR limb)
Had a tough case this week – 30 odd yo. man came off his motorcycle and suffered a random puncture to the upper thigh, just below the inguinal ligament. He arrived 20 minutes after the accident with a BP of 70/50. Interestingly his pulse rate never got much above 100. The old ATLS classification of shock is far from an ideal tool – sometimes you just gotta look at the whole patient! This guy was going unconcious due to cerebral hypoperfusion – that is enough for me to say he has big time hypovolemic shock!
There were a lot of great learnings from this case – my first really disciplined attempt at achieving MAP of 65 and titrating drugs / blood products to achieve this end.
We found no other injury or explanation for the shock – so it was a matter of getting off to the OT for exploration, but we needed to control the loss as it is a good hour until theatre is ready to roll on a weekend. So we placed a torniquet above the wound and rendered the limb pulseless. Seemed to work well, and he was “fluid responsive” after this. Initial ABG showed a lactate of 7.8! pH 7.15… so we were well behind the 8-ball. After half an hour of resus, the leg was looking cold and mottled, making the nurses a bit nervous!
This case was timely as I had just finished listening to Dr Jeffery Guy’s Surgery ICU Rounds podcast on the topic: torniquet use in limb trauma.
Check out this study from Iraq Col. John F. Kragh et al showed that the early application of a good torniquet in limb trauma significantly reduced mortality and did not result in a higher rate of amputation / limb injury secondary to the torniquet use.
To cut a long lecture short – the experience of the US military in Afghanistan / Iraq has shown that with the use of better body armour and IEDs – the limb trauma is now the biggest preventable killer of soldiers in these wars. The use of field torniquets has now become universal and they have some good data looking at the success and morbidity associated with this practice. Basically, if you get a torniquet on before shock sets in – the patient does a lot better. There was little downside – no more amputaitons or permanent disability due to prolonged torniquet time.
Intuitively this makes sense when you consider the risk associated with the lethal triad of: acidosis / shock, hypothermia and coagulopathy.
How does it translate back to our civilian ED / Ambo service? Well not entirely the same, but I think I will be applying a torniquet early and getting to the OT ASAP next time this happens!
Oh, they found he had severed his profunda femoris artery in the thigh in case you were interested. Hb never dropped with the blood only resus!
I finally got some IV tranexamic acid (see Massive Transfusion protocol) in my Resus room – but I didn’t use it on this case – not sure why – would you have given it based on the CRASH-2 data?
Comments or shared experiences welcome, Casey
Interesting stuff. One of my old vascular consultants hated torniquets – if you had to transfer someone with limb trauma he preferred you tie off the bleeding vessel (not blindly clamp, another of his pet hates!) and transfer for definitive care. I haven’t yet had a chance to look at the other talks you mentioned but it’d be interesting to know if reperfusion injury is a big deal in these cases, especially with a pre-procedural lactate that high.
Interesting article. Just reminded its common place in theaters electively we’d use a torniquets upto 90-120min to reduce blood loss in limb surgery.
I guess you have to look at the risk benefit ratio. An elective knee op – you want a quick torniquet time to avoid unecessary tissue injury / hypoxia etc. However, if you are bleeding out from a femoral vessel, then the ratio becomes easy to assess – the theorhetcial risks are low, the actual risk of death is high. I think the studies showed that the benefit is really there if you do it early – before the patient is sick, hypoperfusing elsewhere etc.
As for clamping or tying off vessels – sounds good, but often impossible in practice. In the face of active bleeding it can be really tricky to identify the bleeding vessel without a torniquet – especially a ragged / messy wound. All in my experience – sans evidenc…
Up that high, it would be quite difficult, but my old prof said that the thing to do is put one gloved finger on the bleeder, and have your other hand holding your phone calling theatres. This is especially in the more distal limb where there are multiple vessels.
Do you guys have combat application tourniquets (those groovy ones with the windlass)? I played with one when visiting our local retrieval service hangar a couple of years back, but I don’t think the local ambos carry them. Worth getting for the prehospital bag?
I have had a few patients with brachial artery lacerations from slight intoxication with testosterone. I have just placed a blood pressure cuff on (simple kit that we all have) and ensuring it stays up. Then once things settle down see if I can locate the offending artery if not i just keep the cuff up while waiting for Minh and friends.
Re the vascular profs: It is all well and good to say that torniquet’s are bad but if I have a lacerated artery cannot control with simple pressure have long distances to travel and no blood products i would prefer the torniquet and cant get to theatre to tie it off or cant tie it off.
The great thing about this blog is highlighting the differences between the tertiary referral centres with all the resources vs the reality of working in rural/remote settings. If you have access to theatres, vascular surgeons, blood products galore with a distance travel of 100metres then sure no torniquet but if you have large distances or hostile enviornment, no backup, minimal resources torniquet will likely save the patients life.
Agree with Ray
RFDS QLD are going to get combat tourniquets for our retrieval gear.
simple, effective and cheap.
Useful as well for field amputation
What was old is new again…