A 20-year-old man, a civilian, of nationality, added that during a pirate attack on a merchant ship suffers three wounds (one in the abdomen and two in the thorax) by firearm.
The wounded person is evacuated by staff of the Trozo de Visita y Registro (with health training in basic life support) in a semi-arrigid lancha until the A-11 "Marqués de la En
In the out-of-hospital phase (also called the Zero phase), the hemodynamic stability and the absence of external bleeding are confirmed, as stipulated in the CCR (Tactical Combat Casualty Care), which determines the
There, the first resuscitation measures are initiated according to ATLS postulates.
A primary evaluation was made, observing that the patient is conscious (GCS 14 points -O3V5M6-), with the airway permeable and stable respiratory and hemodynamically.
The secondary evaluation showed three gunshot wounds (the first at the level of the right hypochondrium and the second and third in the right hemithorax) with minimal active bleeding.
The wounded patient had an SaO2 97%, a heart rate 95 bpm, non-invasive blood pressure 94 mm.Hg, respiratory rate 13 bpm, and axillary temperature 36.3 oC.
1.
Outbreaks of external bleeding are treated by direct compression and application of ultrasound (CeloxGauceTM), although the abdominal presence and thoracic trauma are not very effective and direct compression penetrates.
Treatment is initiated with 6% Venturi mask, 31%; After two peripheral venous accesses (18G and 16G) in the upper limbs, fluid therapy is initiated with 500 ml of colloid solution 130/0.4.
Fentanyl (50μg i.v.), kerostomia (50 mg i.v.), cefazolin (2 g i.v.), metronidazole (500 mg iv) and a dose of tetanus toxoid are administered.
Hypothermia is controlled with passive heat measures.
Blood component transfusion is not performed at this level.
After 7 hours of admission to Role 1 of the vessel and after being placed in a state of evacuation, the destination of a rotating aircraft AB 212 of the Spanish Navy in MEDEVAC configuration is determined.
Such a long stay in the first health step and in the presence of a sick leave with abdominal trauma is not acceptable; here it is justified by the tactical situation of the incident that occurred many miles off.
The evacuation time is 60 minutes at a flight coat of approximately 300 feet.
During the aero-evaluation, the loss remains stable.
Upon reaching the second medical step (Role 2) of this area of operations (Groupement Medico Chirurgical Bouffard de Yibuti), an orderly transfer of the sick leave is performed in a French health facility.
In the first phase, a complete reassessment is carried out and a first protocolized management ATLS (Advanced Trauma Life Support) is established in the triage zone, after complete exposure and secondary evaluation of the injury pattern.
Fluid replacement therapy (Ringer Lactato) was continued, followed by analgesia with beta-blockade.
The ECO FAST (Focused Assesment Sonography for Trauma), not usually available more than in these second steps, confirms the presence of a right intrathoracic effusion combined with free abdominal fluid.
Radiologically assisted proycetates show the presence of a projectile at the right flank level and two metralla fragments in the right hemithorax, right pleural effusion and absence of bone lesions.
Blood tests revealed hemoglobin 9 g/dl, platelets 110,000, BE <6 mmol/l and lactate 2.5 mmol/l.
Right thoracic drainage was placed with 500ml of self-limiting content.
1.
During the second phase (damage control procedures, with hemorrhagic focus and contamination), surgery is performed following the premises of damage control.
It is performed at this level because it is the first step where there is a surgical team able to perform them.
The presence of the three lesions was confirmed and under general anesthesia a xipho-pubic laparotomy was performed.
At the beginning of the procedure 450 ml non-contaminated void contents were removed from the peritoneum.
A 1 cm long Bauhin valve wound in the small intestine was observed.
Resection of 20 cm of small intestine at the level of the lesion was performed without restoration of intestinal continuity.
Hemostasis is required by suturing the bleeding point in the mesentery.
Temporal closure of the abdominal wall was performed using a VAC device (Vaccum Assited Closure).
In the third phase (affective care unit), a proportionate blood replacement is initiated, transfusing a total of 3 units of fresh concentrate and 3 units of frozen plasma.
Four days after admission to this unit, it is considered that given the stability of the patient's discharge, definitive surgical treatment can be performed.
Finally, in the fourth phase (definitive procedures), intestinal continuity is restored by means of mechanical lateral latero-lateral anastomosis, surgical debridement of the two entry orifices, closed intraperitoneal drainage through the right iliac mesh aponeurosis.
No projectiles can be found.
Readmission to the intensive care unit
After 10 days in this unit and after hemodynamic stability and normalization of intestinal transit, thoracic drainage was removed and discharge to the hospital ward was decided.
