JUNCTIONAL STAB WOUND SAVING THE UN-SAVABLE
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1 JUNCTIONAL STAB WOUND SAVING THE UN-SAVABLE MARVIN WAYNE, MD, FACEP, FAAEM, FAHA ASSOCIATE CLINICAL PROF. DEPT. OF EM, UNIVERISTY OF WASHINGTON EMS MEDICAL DIRECTOR WHATCOM COUNTY WA EMERGENCY DEPT. PEACEHEALTH ST. JOSEPH MEDICAL CENTER BELLINGHAM, WA
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5 27M -911 Patient assaulted by acquaintance with a knife Stab wound L groin lots of blood.. Small abdominal stab wound Wife call 911, bleeding not breathing What should dispatch instruct wife? Do CPR?, pack and hold wound? Something else?
6 27M -EMS Patient s wife claims attacker gone EMS arrives 11 minutes after the call stage for LEO? Go right in or what? LEO arrives 16 min after first call, wife doing CPR per dispatch EMS cleared to enter
7 27M -EMS Small abdominal stab wound Large junctional laceration left femoral artery EMS arrived 11 minutes after the call LEO in first, wife doing CPR per dispatch
8 27M -EMS LEO attempted tourniquet and packed wound EMS found pt pulseless and unresponsive in a large pool of blood with a tourniquet to the LLE placed by LEO Tourniquet repositioned Continued holding pressure to the wound, CPR continued Patient rapidly transported with ongoing CPR During transport intubation with ITD, 2 IOs and some fluid Short transport time, no time for TXA.
9 27M-EMS/ED Stab wound of L thigh w/ transection femoral artery, transection left femoral vein, transection left great saphenous vein, transection left femoral nerve Stab wound of abdomen w/ mesenteric lac Traumatic hemorrhagic shock Cardiac arrest due to trauma Anoxic brain injury Acute kidney injury, 2⁰ ischemic ATN
10 27M ED 1956: Pt. arrived as FTA, pulseless fixed pupils CPR in progress. LUCAS device applied. 2001: Trauma surgeon arrived-decision to go for it : Central line 3 mg epi, 2 units of PRBCs and 4 L of NS No TXA 2015: ROSC, MTP ordered 2025: Vascular surgeon arrival 2040: 4 th and 5 th units RBCs completed 2046: Pt. taken emergently to the OR for repair of uncontrolled bleeding
11 : 27M-OR Repair of left femoral vein with saphenous vein graft Repair of left femoral artery with saphenous vein graft Ligation left great saphenous vein Exploration left femoral nerve, placement of marking stitches Thrombectomy left femoral/popliteal artery 0020: Exploratory laparotomy and repair of a mesenteric laceration Received total of 6 units of PRBC, 8 FFP, 1 platelet pack, 2 cryo
12 1/14: Admitted to ICU post-op. 27M-POST OP ICU Concern: hypoxic ischemic encephalopathy-started full TTM protocol 33 0 C 24 hr using ECD After slow rewarm pt began to awaken, slow return of memory, except STM Other complications: acute respiratory failure, ischemic hepatitis, and acute kidney injury secondary to ischemic ATN. 1/16: Pt. extubated
13 27M-POST OP ICU 1/18: Nephrology consult. Pt. non-oliguric, creatinine 8, K /21: Re-intubated. Dialysis catheter placed. Creatinine 9.7, K 4.8; hemodialysis initiated. 1 unit PRBC for 1/22: Pt. extubated 1/24: Pt. re-intubated. Received 1 unit PRBC for Hct 19.6
14 27M-ICU 1/26: Pt. extubated 1/31: Dialysis catheter removed, last HD on 1/29 2/2: Hct drifting down, from 35.4 on 1/31 to 17.9 on 2/2. Two units PRBC given 2/3: Taken back to OR for exploration/evacuation of left thigh hematoma, muscle flap closure and placement of wound vac
15 27M-ICU AND BEYOND 2/4: Neurologically improved. Working with PT/SLP, will be NWB to L leg for 4 weeks. Continues to have poor appetite, nausea/vomiting 2/8: Transferred to 3 rd Surgical 2/13: Transferred to rehab. Still has some impaired memory, possible residual anoxic BI
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