|
After a few seconds of the tourniquet takedown in the trauma bay, this wound cut lose. The hemorrhage was not arterial as it did not spray out in a pulsatile fashion but was high flow, low pressure bleeding. We reapplied a bandage and had a faint pulse in the dorsalis pedis and posterior tibial. The Air Evac tourniquet was a pneumatic cuff and it did "OK".
We did the C-A-B-D-E trauma algorithm. That is, control the bleeding first and then move back to your A and B. His respiratory rate settled down with blood and eventual intubation as he had all of the hallarks of shock (class 3 at least). We pulled two units of O negative blood from the trauma bayrefrigerator and started to transfuse as he was white as a ghost. We continued with the IV resuscitation. The goal was to get vascular control ASAP and the only way to do this was going to be in the OR now! We knew from the air crew and the outside hospital nurse's reports that this was not just a flesh wound as had been painted for us by the referring physician. We gave him a tetanus shot, 2 grams IV Ancef and went straight to the OR.
No need for a pre-op angiograms or CT scans as we knew something was bleeding more than just the skin and muscle. That would have meant more time, more bleeding and no new information that we couldn't get in the OR.
While half of the surgery team scrubbed, I helped prep and drape the patient. A sterile tourniquet was applied. Once we were in the sterile field and the wound, we opened up the fossa in a medial popliteal approach and got venous/arterial proximal and distal control to be able to release te tourniquet. We had prepped the opposite groin in case we needed to harvest vein for a repair and we ended up using it. We found a transected politeal vein which we sewed back together primarily. The nerve was banged up pretty bad but not transected and besides he had minimal deficit on motor or sensory examination in the trauma bay. The artery was also partially transected and was on its way to thrombose. This is why it did not bleed on us in the trauma bay as it was already clotting off. So, we opened the artery, thrombectomized the clot and did a vein patch angioplasty. We reconstructed his muscles, tendons and skin and his post-op angiogram revealed a patent artery. We did complete a four compartment fasciotomy due to the length of time of arterial ischemia, tightness of the calf at the end of the case and prior hypotension. We sent him up to the ICU and did not extubate as he had over 10 liters of fluid, 12 units of blood and he was very swollen.
We extubated him on post-op day 2 (or 48 hours later). He was transferred onto the floor on ASA, Plavix and Coumadin to assist in keeping the repairs open. His pain improved and we had physical therapy ambulate him. He was discharged with follow-up.
Always assume the worse and that the history given is always missing something. Never take anything for granted and show up with your game face on. Always ask, re-ask and then ask again. Make sure the nurses and the air crew call report. Be there when the patient arrives so that you see the wound yourself and see how the patient is doing or responding to the therapy.
Here are some intraop photos and a photo of the post-op angiogram.
Dutch
|