[swatsurgeon]

I couldn't help but notice the EZ-IO identification bracelet.... on the severed arm

- Dczilla, the patient was so hypotensive, no peripheral access was able to be obtained so they inserted an EZ-IO in the tibia.

1. Advanced airway w/ c-spine. Wound to rt cheek and blast on that side would tell me massive baro trauma as well.
2. Ready to suction. Monitor breath sounds as best as poss.
3. Ligate, ligate, ligate. Hemostatic control agent. Package tight. Multi large bore IV. I like the IO. Bilat if poss.
4. Airevac to Neuro and vascular surgery. Pack limb to go with.
5. Be ready for a combative patient unless you have RSI or sedation meds.

Great case. How was the outcome, if I can ask. Thanks. adal

adal, airway was secured with ETT once arrived at hospital, he was breathing spontaneosly and airway was not compromised....could have become that way with the effects of a blast injury, intubation at any point would be okay but IMHO, after getting hemostasis if he is breathing.
Ask yourself a question, which vessel, axillary/subclavian ARTERY or VEIN will be the one to let you bleed out the quickest??
The artery has muscle in it's wall and typically will close itself off quickly which is what happened to this guy, The vein is thin walled and has no such contraction properties and will remain an "open faucet" until pressure is applied or it is ligated. DIRECTED pressure was held to the site of bleeding, not a big bulky 'pressure dressing'...that would have allowed him to continue hemorrhaging and die. Could you use a hemostatic agent, hell yes, put quik clot on it hold fast...sorry, no tourniquet on this one, can't place it above the site, no purchase to hold on to the entire arm is gone.
Limb went with him but under the circumstances of maximal 'dirty' conditions with disrupted bone, soft tissue, nerve and artery and vein (not a clean 'saw type' cut), the arm isn't going to be re-implanted.
Remember, this is rural and farm country....must use a penicillin type drug, in addition to others,, very specific bacteria with farms, etc, CAN'T forget this.
evac where a surgeon can take care of bleeding, nerve is way down the list of priorities for this particular injury.
Look for other injuries: chest penetration...hate to stop bleeding and have him die of a missed tension pneumothorax!

Intra-op pics attached: showing socket of shoulder, dealing with vessels and nerves, showing non-implantable staus of soft tissues/muscles.

He survived the operation, 8 units of blood, had a significant metabolic acidosis requiring aggressive resuscitation. I thought his shock state would kill him but he survived and improved with alot of work/efforts. No other major injuries other then his ear hanging off that we fixed in the ICU. Managed the nerve appropriately to minimize post op phantom pain.
More later.

ss