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Rollover Car Crash Almost Costs Driver his Life, Limb

Case-tourniquet

It’s easy for a current and former military physician working in a busy urban trauma center to look around and see the countless advances in trauma care that have been translated from the military to civilian experience. This month’s case highlights just one of the many lessons learned from caring for injured service members.

Prehospital Course
When a 72-year-old male who was driving unrestrained in his sedan along the highway was suddenly struck from behind, he lost control of his vehicle and it rolled. His left arm, which was resting in the open window, was crushed.

Philadelphia Fire Rescue medics arrived at the scene and found the patient in a large pool of blood with a severely deformed left arm dangling by what seemed to be a thin connection of soft tissue. There was profound, pulsatile bleeding. Medics applied a tourniquet to the arm above the injury and tightened it until the bleeding stopped. They then immobilized the patient on a spine board, obtained IV access and administered morphine for pain control, splinted his arm with blankets as best they could and transported him to the trauma center at the Hospital of University of Pennsylvania as a “trauma alert,” the highest level of activation. The patient remained hemodynamically stable during the transport.

Hospital Course
On arrival, the trauma team quickly completed a primary survey, attached the patient to monitors, exposed and rolled the patient, and obtained additional IV access. Initial vital signs were heart rate=126, blood pressure=162/100, respiratory rate=20, temperature of 96.9° F and pulse oximetry of 100%. His Glasgow Coma Scale score was 15. Secondary survey was notable for some spinal tenderness, abrasions on the back and the obvious near amputation/de-gloving deformity of the left forearm. The tourniquet was in place above the elbow, and the bleeding was stopped. A focused assessment with sonography in trauma (FAST) ultrasound exam showed no blood in the abdomen, and a chest X-ray was unremarkable.

The tourniquet was carefully released to better examine the arm. This resulted in severe pain for the patient in the area above and surrounding the wound. Pulsatile bleeding appeared to emanate from the vicinity of the radial artery. A limited neurologic exam of the hand with the tourniquet released revealed no evidence of motor or sensory function during this brief interval. Because of the persistent bleeding, the tourniquet was reapplied.

The patient remained in extreme pain and became agitated. At this point, since a neurologic exam had been performed and the patient would be going to the operating room (OR), the medical team proceeded with elective endotracheal intubation to provide adequate sedation and analgesia. Following intubation, the patient was brought to the computed tomography (CT) scanner for imaging of his head, C-spine, chest, abdomen and pelvis. No other injuries were identified.

The Operating Room
The patient was brought to the OR and underwent repair of the radial artery, ligation of the ulnar artery, external fixation of the radius and ulna, extensive irrigation and debridement of devitalized tissue, and wound coverage with cadaveric skin. He was extubated the following morning, and examination of his hand revealed mostly intact sensation and slight movement in his thumb and fingers.

Of note, the patient’s medical history was significant for coronary artery disease and deep vein thrombosis. On initial evaluation, he reported taking aspirin, clopidogrel and warfarin. He was treated with vitamin K via IV and transfused with fresh frozen plasma and platelets for presumed drug-induced coagulopathy. His initial hemoglobin was 10.3 gm/dL with an international normalized ratio of 1.1. Given his history of significant blood loss and ongoing hemorrhage, he was transfused three units of packed blood cells in the OR. His tetanus status was unknown, so he received a tetanus vaccine. He was treated with broad spectrum antibiotics for his open, severely contaminated fracture.

At the time of this article, the patient had left the intensive care unit, but he remained in the hospital three weeks. On the road to salvation of his limb, the patient had five surgeries, including placement of antibiotic impregnated beads and free-flap tissue transplantation.

Discussion
Exsanguinating hemorrhage from isolated extremity trauma in the civilian setting is rare. Unfortunately, due to mixed messages in much of the civilian medical literature and first aid texts, many providers are hesitant to place a tourniquet for fear of causing further injury or committing the patient to an amputation. The military experience during the past several years, however, has demonstrated how this simple technology can be both life- and limb- saving.

Historically, the mortality rate from exsanguination from extremity trauma on the battlefield has been approximately 9%.1 A retrospective study of special operations personnel deaths in the global war on terror found that 13% of the potentially preventable deaths might have been prevented with a tourniquet.2 Likewise, a large prospective study examining the use of prehospital and emergency department tourniquet use in a combat support hospital in Iraq found that early use of tourniquets not only provided hemorrhage control but also improved mortality.

In a series of more than 400 applied tourniquets, no amputations were associated with inappropriate tourniquet use, and few were associated neurologic complications.3 For these reasons, in 2005, the U.S. Army adopted a new standard Tactical Combat Casualty Care guideline that tourniquets should be first-line treatment for any life-threatening extremity trauma while under fire.

Although extremity trauma in the civilian setting is rare, studies show that it’s deadly. A similar retrospective study of exsanguinating extremity trauma in the civilian population identified 14 patient deaths during a period of five and a half years at two Level 1 trauma centers in Houston. Of these 14 patients, 57% had wounds that would have been amenable to the placement of a tourniquet, and therefore potentially could have been saved.4

ConclusionGiven this information, civilian EMS providers should feel confident that placing a tourniquet for severe extremity hemorrhage that isn’t controlled by other means is safe, appropriate and life-saving. Studies also show they should be applied early and before the patient is in shock.3

A variety of tourniquets are available for EMS use. EMS units should work with their medical directors to select and train with the device that best suits their needs. As this case illustrates, the use of a tourniquet was lifesaving for this patient and should always be considered in cases of severe extremity trauma.

When placing the tourniquet, providers should remember the following:
>> Tighten until all bleeding stops. If the wound is still bleeding, you likely have a venous tourniquet, and it may need to be tightened further or repositioned in order to occlude all arterial inflow.
>> Place as low on the extremity as possible.
>> Note the time that the tourniquet is applied. (Paperwork gets lost and people don’t always listen during the report, so write it on the patient too!)
>> Tourniquets are extremely painful; administer some pain medication.
 
Disclaimer: The views expressed in this presentation are those of the author and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, or the U.S. government. Dr. Polk is a service member. This work was prepared as part of his official duties. Title 17, USC, §105 provides that “Copyright protection under this title is not available for any work of the U.S. government.” Title 17, USC, §101 defines a U.S. government work as a work prepared by a military service member or employee of the U.S. government as part of that person’s official duties.

References

1. Bellamy RF. The causes of death in conventional land warfare: Implications for combat casualty care research. Mil Med. 1984;149(2):55–62.
2. Holcomb JB, McMullin NR, Pearse L, et al. Causes of death in U.S. Special Operations Forces in the global war on terrorism: 2001–2004. Ann Surg. 2007;245(6):986–991.
3. Kragh JF, Walter TJ, Baer DG, et al. Survival with emergency tourniquet use to stop bleeding in major limb trauma. Ann Surg. 2009;249(1):1–7.
4. Dorlac WC, Debakey ME, Holcomb JB, et al. Mortality from isolated civilian penetrating extremity injury. J Trauma. 2005;59(1):217–222.

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