A 30-year-old Afghan official was evacuated to RoLE 2 of Herat from ROLE 1 of Farah for a gunshot wound in the right inguinal region.
Her personal history included tracheal stenosis due to a gunshot that had been suffered years ago.
In ROLE 1, an exploration of the wound was performed and a 10F Argyle shunt was placed in the femoral artery, after finding a substantiate loss that affected the limb at 80 cm below the inguinal fold, 10
During admission, he required 8 concentrates, 9 platelets and 1 coagulation factor.
On his arrival at ROLE 2, he was intubated.
Blood pressure values were 13/7, heart rate was 74 beats per minute and no fever was found.
Blood tests showed a platelet count of 67,000 and INR of 1 ́4, although there was no acidosis and lactate was normal.
The limb was warm and barefoot or tapered, but distal pulses were not palpable.
The radiological study did not demonstrate the existence of fractures.
Therefore, given the difficulty of referring the patient to a reference center, it was decided to perform a wound exploration.
The entrance orifice, 1 cm in diameter, was in the middle third of the outer thigh, and the exit orifice, on the inner side, near the adductor canal.
The wound bed was swollen and there was no venous compromise.
The femoral artery was located in 80% of its circumference.
Then, an incision was made on the inner side of the contralateral thigh until the saphenous vein was dissected using blunt dissection and electrocoagulation.
After ligation of collaterals and both ends, a 4 cm graft was obtained, which was irrigated with heparinized saline solution to demonstrate the absence of leaks.
After this, systemic anticoagulation was initiated with 3000 IU heparin, taking into account the elevated INR and platelet count.
The clamping of the arterial cables was controlled to evacuate the possible neoformed thrombi and heparinized serum was applied.
The venous graft was inverted and sutured continuously with 5/0 Prolene.
The presence of distal pedal and posterior tibial pulse was verified with ultrasound and the wound was copiously washed with saline solution.
The subcutaneous tissue was closed with Vicryl 3/0 covering the rectified artery.
During his stay in the Intensive Care Unit, the presence of distal pulses with ultrasound was checked every hour, as well as temperature and appearance of the limb, without observing any anomalies until the patient was transferred 24 hours after admission.
Analgesia was controlled with fentanyl and lidocaine.
Cefazolin 1 gr was administered every 8 hours and anticoagulation was maintained with 25,000 IU heparin in 500 cc serum at 500 units per hour.
