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

 

 

 

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