We report the case of a 29-year-old man (165 cm, 68 kg), aphagous, policeman, who suffered an open trauma in the right elbow secondary to the impact of a firearm (probably AK).
After the incident, a tourniquet was placed at humic level and a topical granuleuse iv was applied (Celox® SAM Medical Products, Newport, Oex administered gtragon acid).
She was evacuated through a medicalized helicopter until the Spanish Role 2E of Herat (Afghanistan) reaching the triage room 70 minutes after suffering the injury.
1.
In the primary assessment, the wounded patient had GCS 15 ptos, peripheral SatO2 98%, heart rate 110 bpm, non-invasive blood pressure (30/10 mg iv) and midazolam 3/10 mg iv) with good control of pain.
The presence of a gunshot wound with an entry orifice in elbow without an exit orifice was confirmed.
Radiography showed a distal fracture of the left hilum, a proximal fracture of the left cubitus and a proximal fracture of the left radius.
It was decided to perform a surgical intervention for debridement, cleaning, removal of bone schirs and placement of an external fixator on the left arm under general anesthesia.
Changes in blood tests, ECG or airway assessment were not considered during the study.
The patient did not remember anything but had been his last ingestion and accepted the informed consent in the presence of an interpreter.
In the operating room, a grade I monitoring (peripheral SpO2, heart rate, non-invasive blood pressure and capnography) was used, together with a bispectral analysis device (BIS®), a continuous hemoglobin monitor (Masimo®).
The wound was premeditated with midazolam (1 mg iv) and with beta blockers (20 mg iv).
After 3 minutes of denitrogenization with 80% FiO2 and 100% SatO2, rapid sequence anesthesia was induced with fentanyl (30 μg iv), propofol (130 mg).
Standard laryngoscopy (Cormak II) was performed, the airway was isolated with a 7.5 mm endotracheal tube and the endotracheal cuff was filled with air (8 ml).
After selecting protective ventilation parameters (VT 420 ml, PEEP 7, FiO2 45%), alveolar recapping maneuvers were not necessary.
Anesthesia was maintained with O2, air and sevoflurane mixture.
During the 75 minutes of the surgical procedure, the patient remained prone to tachycardia.
The intervention performed was open reduction under control of scopy, transarticular osteosyntesis by implantation of external fixator Hoffmann II Stryker in multiplanar configuration, pulsatile lavage of the ulnar flexor tendon and necrotic tissue.
Antibiotic prophylaxis was administered with warm air-protected fluids 2 g iv metronidazole 500 mg iv), gastroprotective (omeprazole 40 mg iv), antiemetic (greisetron 3 mg iv), antiepileptic
To improve pain control, in addition to performing multimodal analgesia (metamizole 2 g IV, paracetamol 1 g IV, acetaminophen 30 mg IV and fentanyl 150 μg IV) an ultrasound-guided peripheral nerve block was used.
Opioid antagonists and muscle relaxant reversal were not required.
The patient was admitted stable and with good pain control in the intensive care unit and then transferred to the hospital ward.
The patient was discharged from Role 2E 72 hours after suffering the condition, and was evacuated to an Afghan military hospital for soft tissue healing and future osteosyntesis.
