TY - JOUR T1 - Salvage of the injured upper extremity JF - Trauma Surgery & Acute Care Open JO - Trauma Surg Acute Care Open DO - 10.1136/tsaco-2021-000799 VL - 6 IS - 1 SP - e000799 AU - David V Feliciano Y1 - 2021/09/01 UR - http://tsaco.bmj.com/content/6/1/e000799.abstract N2 - A 48-year-old man playing cards was accused of cheating. An assailant with a shotgun wounded the victim in the area of the right biceps muscle. When personnel from emergency medical services arrived, they applied a pressure dressing to the right arm to control profuse hemorrhage.The patient was awake and alert with a heart rate of 130 beats per minute and a systolic blood pressure of 110 mm Hg. The pressure dressing over the right arm was saturated with blood and was removed. Findings on examination included the following: a 20×12 cm cavity in the anterior right arm; absence of much of the right biceps muscle; absence of the brachial artery and venae comitantes; an intact median nerve; limited function of the right elbow; intact function of the right wrist and fingers; and absent right radial and ulnar pulses at the wrist.A pressure dressing was reapplied to the open wound in the right arm. As a blood specimen was drawn for type and cross-match, resuscitation with a crystalloid solution was initiated. An X-ray of the right arm documented that the shotgun pellets were all in the area of the right biceps muscle (figure 1). After administration of a cephalosporin antibiotic, the patient was moved to the operating room.Figure 1 X-ray of the right humerus documents no fracture and limited distribution of pellets.Skin preparation and draping included the chest and the entire right upper extremity from the left nipple to the right fingernails and from below the umbilicus to the toenails bilaterally. After the pressure dressing was removed, there was profuse venous hemorrhage from the open wound in the anterior right arm. Attempts at suture and metal clip control of multiple open veins had an only modest effect on controlling the hemorrhage.Based on the injuries described, your choice … ER -