Trauma Resuscitation Demonstration in a Stable Patient with a Minor Perforating Wound
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This is the case study of a 17-year-old male Reserve Officers’ Training Corps (ROTC) cadet who suffered a superficial perforating saber wound to the medial part of the right knee during a routine practice session. This video demonstrates the step-by-step patient assessment process and subsequent saber removal, providing a detailed account of the challenges faced by the personnel.
The assessment focused on understanding the circumstances surrounding the injury, taking into account the patient's health status and the specific anatomical details of the wound. Upon arrival, the patient was still holding the saber in place to stabilize it. The patient was carefully repositioned for further evaluation. The patient's airway was checked, and blood pressure was measured manually. The patient was laid bare for a thorough examination, and monitors were strategically placed to closely monitor vital signs. Vital signs and medical history including details about the tetanus vaccine and allergies were recorded parallel to physical examination. Intravenous (IV) access was established and fentanyl was administered.1
With the patient stabilized, the team initiated the delicate process of removing the saber. Precision is of critical importance to avoid the potential exacerbations of the injury. Following successful saber removal, the two 1-cm lacerations in the area of the right medial thigh were evaluated to ensure the absence of any signs of vascular injury. Preparations were made for a posterior examination to assess for potential injuries on the back, axillary, perineal areas, and the spine. The patient's movement was carefully coordinated to minimize discomfort. Additional injuries were ruled out. Before motor and sensory assessments of all extremities, the bilateral femoral and posterior tibial (PT) pulses were meticulously evaluated, ensuring the absence of any alarming indicators such as those of ischemia. The potential for an expanding hematoma or pulsatile bleeding were likewise excluded during the exam. X-rays of the right femur and knee were performed to identify potential fractures.
After completing the secondary examination, which included motor and sensory assessments,2 the arterial pressure index (API) was obtained. In the context of this case, the API played a pivotal role in assessing the vascular integrity of the affected limb and ruling out any potential injuries to the distal superficial femoral artery (SFA) and the proximal popliteal artery (PA). The API is a non-invasive and reliable tool used to evaluate the perfusion of the lower extremities. A blood pressure cuff was applied to the patient's injured ankle, and after it was then placed around the ankle of the uninjured leg in order to check both sides. The systolic blood pressure was measured at both ankles. The API calculation involved dividing the systolic pressure of the injured ankle by the systolic pressure of the uninjured ankle. A value of 0.9 or higher (generally considered normal) in this case, indicated adequate blood flow to the extremities.3 In cases of trauma, especially with penetrating injuries, a lower API might suggest arterial compromise and prompt further investigation.
Systematic assessment, precise execution of medical procedures, and effective collaboration between medical personnel are crucial in such clinical scenarios.4 This case serves as a valuable resource for healthcare professionals, offering insights into the critical aspects of patient evaluation and wound management in unique trauma situations.
The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.
Citations
- Fabbri A, Voza A, Riccardi A, Serra S, Iaco F De. The pain management of trauma patients in the emergency department. J Clin Med. 2023;12(9). doi:10.3390/jcm12093289.
- Clark A, Das JM, Mesfin FB. Trauma neurological exam. StatPearls. Published online 2021.
- Tung L, Seamon MJ, Dauer E, et al. Using arterial pressure index to predict arterial injuries in penetrating trauma to the upper extremities. Am Surg. 2023;89(1). doi:10.1177/00031348211011142.
- Khademian Z, Sharif F, Tabei SZ, Bolandparvaz S, Abbaszadeh A, Abbasi HR. Teamwork improvement in emergency trauma departments. Iran J Nurs Midwifery Res. 2013;18(4).
Cite this article
Priya Prakash, MD. Trauma resuscitation demonstration in a stable patient with a minor perforating wound. J Med Insight. 2024;2024(299.4). https://doi.org/10.24296/jomi/299.4Procedure Outline
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Transcription
CHAPTER 1
Okay, so he is 17. He's in the ROTC program,and they were practicing some kind of maneuver with the swords.He dropped it, and he's got a penetrating injury to like the -medial part of the right knee, and then -and there's like an entrance, and then it's got -a couple centimeters below it is an exit.So it's still in, we just have it stabilized.He has good CMS, he's been holding it kind ofstill here to keep leverage off it because it's kind of a long saber.Can you tell me your name?Okay, airway's intact.On Will's count, we're going to move on three.Ready? One, two, three.Okay.Can you bring the bed up a little bit?Ouch.All right, guys.I'm going to listen to you.So we're going to expose the patient,we're going to get him on the monitors,we'll establish two large bore IVs, and we'll get a manual blood pressure.Take a deep breath for me. Can I have scissors, please?Take a deep breath.Yes.All right, lung sounds are clear bilaterally.Do you have any allergies?No.Do you have any other medical problems? No.Ah!Sorry bud. Nope.How much do you weigh? We're going to leave that, right?I'm not too sure, maybe 170.170 lbs.How tall are you? 6' 3".6' 3".Do you have any allergies? No.120/82.120/82. Okay.We'll send a full set of trauma labsonce we get IV access in. All right, thumb pulses are intact.Left DP's intact.Right and left DP intact.Pardon me?When did you last eat something?Lunch time, around noon-ish. Can someone grab some warm blankets?All right, can you wiggle your toes for me?Okay, good.Do you know where you are?Pardon me?Do you know where you are? Yes.Okay.DCS of 15.Can we get 50 of fentanyl, please?We'll get some blankets.Big poke, stay still. If you want, there's a pillow behind your head.All right, so I'd say...No allergies, no medical problems, last meal was lunch.There's an 18 gauge in the left hand.After we establish our IV access and we give somepain medication, we're going to attempt to gently removethe sword so that we can turn safely.Okay.Is it sharp on both sides? No.Helen, you can continue with the rest of your secondary anteriorly.Do you have any pain in your head, here? Nope.All right, any pain in your chest?No chest wall tenderness.Any pain in your belly?Megan, 50 fentanyl is in. Can you relax a little bit?Pardon me? Relax a little bit.All right, abdomen is soft, non-tender.
CHAPTER 2
All right buddy, so this looks like it just went through the skin.Okay, it's probably away from any major blood vessels,so that's why we're going to try to remove this so that wecan turn you and look at your back safely, okay?Pelvis is intact. We just gave you some IV pain medication.Ah!Okay.All right.All right, we're going to slowly pull.Do we have any gauze here?You're doing great, almost done, okay?Perfect, it's all out, okay?All right, so it has a laceration to the right thigh -right medial thigh.He's got a 1-cm lac and one right below, another 1-cm lac.Any hard signs of vascular injury?No.He's got good fem pulses and good PT pulses. Okay.No expanding hematoma, no pulsatile bleeding, distal pulses, no leg ischemia, okay?And then do you feel a thrill?No. And no thrill. Okay.
CHAPTER 3
So we're going to get ready to turn to his left side.Okay.The sword is intact.We're going to do all the work, okay?All right, on Will's count. I'm going to touch on your back,you just say "yes" or "no" if it hurts, okay?Don't move your neck.On Will's count, we'll turn to the patient's left.Good, ready - one, two three.All right, tuck all of the clothes underneath him Any pain here? Here?Here? Here? Here? We can get this out.No step-offs,no C, T, or L spine tenderness.All right, I'm going to lift this up. We'll look at the right axilla.Right axilla is intact.All right, we'll look at the right perineum.Go ahead and lift this up here.All right, right perineum is intact. We will defer our rectal.Okay, on Will's count we'll move back supine.Ready? One, two, three.We'll do our trauma shuffle.We're just going to go the other way now.Do you know when your last tetanus shot was?I'm not sure.Was that tetanus shot you just asked? Unsure.Okay.Ready? On Will's count we'll move to the patient's right.One, two, three.I'm going to lift this arm up.Okay, we'll get all the clothes out from underneath him.All right, left axilla is intact.Lift this leg up.All right, left groin's intact.Okay.All right, we'll turn back supine on Will's count. Ready?One, two, three.Okay, and let's just - everyone stay where they are,we'll just make sure he's appropriately positioned on the bed.We can go down a little. We could move him down a little bit.Okay.We can go down like...And maybe to patient right a little bit.Yeah, okay.He's tall. Ready?One, two.Okay, all right.Is that more comfortable? Great.
CHAPTER 4
Helen, we'll have you finish your secondary examwith a good motor and sensory exam of all extremities.All right, good. Do you feel me touching you?Pardon me? Do you feel me touching you?Over here?Yeah, we'll get a right femur and a right knee x-ray.All right, does it feel the same? Yeah.All right, sensation intact in bilateral upper extremities.Do you feel me touching you here? Yes.All right, what about here?Same? Feel the same on both sides?All right, sensation's intact in bilateral lower extremities.Can you push down on my hands?Gas pedal? Okay.Go up.Good.We'll do a FAST exam as well.Any pain in this leg when I press? No.Nothing here? No.Can you bend this knee for me?Bend this knee.Just relax. Bend the knee. Okay, good.Any pain back there? Nope.Can you bend this one a little bit?Any pain back here? No.Here?Right there, yeah.Right there? Yeah.All right, it's tender to palpation tothe medial right thigh.Has good range of motion.And Helen, we'll have you do an API after you're done with your secondary.Do you take any medicines? Nope.All right, have you had any surgeries in the past? No.All right, any recreational -drugs like cocaine, heroin, anything like that? Nope.Do you smoke? No.Okay.I'm going to draw a little blood on your arm here, okay?Okay.X-ray.You want to help me?You want to help me?Femur?Yeah, we'll just get a femur.All right, can you tell me what happened?Me and my friend were practicing our saber team routinefor the upcoming military ball. Okay.And we were supposed to toss the swords across to each other and catch them.I fumbled on the catch and it went into my leg. Yeah, we're just confirming he didn't have any blunt trauma orconcern for any chest problems. Okay, but you didn't fall,or hit your head, or anything else? No.Just the sword?Yeah.Okay.No blunt trauma. Okay.So no chest x-ray.All right bud, we're going to put this under your leg, okay?X-ray.I think you're okay.Right? Because you got the knee.We don't need all the way up there. Okay.Yeah, no, we're good. Thank you.Yeah, it's just that there.So I'm trying to see if you can angle it a little bit.So like 119?So compared to the uninjured...So now do the uninjured extremity.I don't like using that.I don't think it's accurate, and I think that's why we'vebeen getting really inaccurate ABIs and getting CTAs on everybodyOkay.Because this -right?This wound is fairly superficial so very unlikelythat he has a distal SFA or proximal popliteal artery injury.So this was what side, 1...This was 118.118/121 anyway is 0.975.We're just going to finish the API, and as long as that's above 0.9, no.I think it was 138.Try it again? Do this side again.So 138 on that side?Okay, so we'll redo this side.Ready?Mm hmm.Keep going.Okay, can you go a little bit more, yeah.So 132.Yeah, so we're good.