Case Report
58 year-old male with a fin cut and uncontrolled bleeding
History
A 58 year-old male was wave-sailing (windsurfing in surf) and attempting to come to shore. As he was carrying his gear shoreward he was hit by a breaking wave, and the 33 cm single fin on his board caused a large laceration to his left lower leg. The patient described severe bleeding to his leg which could not be controlled with direct pressure from a towel. EMS was called, and they reported arterial bleeding. A CAT tourniquet was placed on the patient’s mid-thigh at the scene. IV access was established, and he was given 75 mg of IV Fentanyl, 1 L of Normal Saline and transferred to a Level 1 Trauma center with a transport time of 45 minutes.
Past Medical/Family/Social History
PMHx: Hypertension
Meds: Lisinopril 5 mg daily
Social History: Occasional Alcohol, non-smoker
Physical Exam
On arrival to the hospital the patient had a heart rate of 115 and a BP of 160/83. He was in moderate distress. He complained of lower leg pain and paresthesia distal to the tourniquet. A blood-soaked gauze was wrapped around the patient’s left mid-calf, and a tourniquet was applied tightly to the patient’s mid-thigh. There were no palpable pulses in the patient’s left foot.
A second IV was established and a CBC, Type and Screen, and Basic Metabolic Panel were sent to the laboratory. The patient was administered 1 mg of IV Hydromorphone. The gauze was cut away revealing an 8 cm linear laceration.
The treating physician gowned, gloved, and placed a protective shield over her face. The tourniquet was gradually loosened, but left in place. There was no active bleeding. The patient’s pain and paresthesia subsided within minutes of tourniquet removal. Pulses were easily palpated in the left Dorsalis pedis and Posterior tibial arteries. Sensory exam in the lower leg and foot were normal. Plain films of the Tibia and Fibula were ordered. A CTA with runoffs of the left lower extremity was obtained to rule out arterial injury.
Test Results, Hospital Course
Hemoglobin:13.2
HCT: 39
BMP: Normal
Tib-Fib X-rays: No fracture. No foreign bodies.
CTA of Left leg with runoffs: Normal flow no arterial injuries.
The wound was irrigated with 1 liter of Normal Saline. It was then anaesthetized with lidocaine with epinephrine. The muscle fascia was repaired with 4.0 absorbable interrupted sutures. The skin was then closely approximated with 4.0 non-absorbable sutures. Bacitracin was applied to the wound as was a dry dressing. Patient tolerated procedure well. The patient was sent home on crutches. Given the depth of the wound, and the fact that it occurred in salt water, he was prescribed a 5 day course of Sulfamethoxazole / Trimethoprim (Bactrim) for prophylaxis.
Discussion
Fin lacerations are common and are likely the most common surfing-related injury requiring medical attention. These injuries can be severe and should be treated like other penetrating trauma such as stab wounds. There have been numerous case reports including in this journal of fin injuries causing pneumothorax, intra-abdominal wounds, splenic lacerations, globe rupture of the eye, and arterial lacerations. See article: Case Report: A 29-Year-Old Female Surfer with a Thigh Laceration. Given the location of this patient’s injury it is likely that he lacerated his saphenous vein and not a major artery. Nonetheless, venous injuries can result in substantial blood loss and even fatal hemorrhage. The take home message here is that fin lacerations should be taken seriously.
Bleeding from the vast majority of wounds can be controlled in the field with direct pressure. A stack of gauze, using direct digital or palmar pressure directly over the area that is bleeding from a gloved hand is ideal. Another option is to place a stack of gauze directly over the area that is bleed and use a tightly bound elastic dressing (e.g. Ace wrap) or tape to hold the gauze firmly over the area that is bleeding. If the wound is large enough, gauze should be placed directly into the wound. However, in the majority of cases those supplies will not be readily available and materials at hand such as a clean towel or T-shirt can be used in place of gauze. Firm pressure should be held for 15 minutes before taking a look to see if the bleeding has stopped. If the dressing is still being saturated with blood, try repositioning the area to which pressure is being applied. If the bleeding cannot be controlled with direct pressure a tourniquet should be applied. DO NOT HESITATE to apply a tourniquet. In most cases of uncontrollable extremity bleeding, a tourniquet applied early will prevent loss of life from exsanguination.
In order for a tourniquet to be effective it must create a band of compression above systolic pressure circumferentially around the extremity and should be applied approximately 2 cm proximal to the wound. The most effective tourniquets are those that are purpose-made; however, few surfers have one at hand. That is the case, a tourniquet must be improvised. The standard technique of wrapping a leash tightly around an arm or leg is usually ineffective because it is extremely difficult to generate sufficient pressure. For more on tourniquets please see the related article on tourniquets in this issue of SurfingMedicine.
