We present the case of a 29-year-old male (165 cm, 68 kg), Afghan, police officer, who suffered an open traumatism to the right elbow during an attack secondary to the impact of a firearm (probably AK-74 7.62 mm). Following the incident, a tourniquet was placed at humeral level, a granulated haemostatic was applied topically (Celox® SAM Medical Products, Newport, Oregon, USA) and tranexamic acid (1 g iv) was administered. He was evacuated by medical helicopter to the Spanish Role 2E in Herat (Afghanistan) arriving at the triage room 70 minutes after sustaining the injury.

On primary assessment, the wounded man had GCS 15 pts, peripheral SatO2 98%, heart rate 110 bpm, non-invasive blood pressure 130/80 mmHg and good pain control (VAS 2/10) after administration of midazolam (3 mg iv) and ketamine (30 mg iv). The presence of a gunshot wound with entry wound in the elbow without exit wound was confirmed. X-ray showed a fracture of the left distal humerus, a fracture of the left proximal ulna and a fracture of the left proximal radius.
Surgical intervention was decided for debridement, cleaning, removal of bone splinters and placement of an external fixator on the left arm under general anaesthesia.
During the pre-anaesthetic study, no significant alterations were found in the blood analysis, ECG or airway assessment. The patient could not remember when he had last eaten and accepted the informed consent in the presence of an interpreter.
In the operating theatre, grade I monitoring (peripheral O2 SatO2, heart rate, non-invasive blood pressure and capnography) augmented with a bispectral analysis device (BIS®), continuous haemoglobin monitor (Masimo® Radical 7) and oropharyngeal thermometer was used. The casualty was premedicated with midazolam (1 mg iv) and ketamine (20 mg iv). After 3 minutes of denitrogenation with 80% FiO2 achieving 100% SatO2, rapid sequence anaesthesia was induced with fentanyl (150 μg iv), propofol (130 mg iv) and rocuronium (30 mg iv). Standard laryngoscopy (Cormak II) was performed, the airway was isolated with a 7.5 mm endotracheal tube and the pneumotaping balloon was filled with air (8 ml). After selecting protective ventilation parameters (VT 420 ml, PEEP 7, FiO2 45%) no alveolar recruitment manoeuvres were necessary. Anaesthetic maintenance was performed with a mixture of O2, air and sevofluorane. During the 75 minutes of the surgical procedure the patient remained tachycardic. The intervention performed was open reduction under scopic control, transarticular osteosynthesis by implantation of Hoffmann II Stryker external fixator in multiplanar configuration, pulsatile lavage of the wound and debridement of the necrotic tissue involving the extesor carpi ulnaris, flexor carpi ulnaris and tricipital tendon.
Anti-tetanus prophylaxis, antibiotic (cefazolin 2 g iv and metronidazole 500 mg iv), gastroprotective (omeprazole 40 mg iv), anti-emetic (granisetron 3 mg iv), anti-inflammatory (desketoprofen 50 mg iv), ocular (oculo-epithelial ointment together with forced eyelid closure), orthopaedic (joint protection) and thermal (operating room temperature regulation, fluid warmer and hot air blanket). To improve pain control, in addition to multimodal analgesia (metamizole 2 g iv, paracetamol 1 g iv, ketamine 30 mg iv and fentanyl 150 μg iv), an ultrasound-guided peripheral nerve block was used at the interscalene level using 37 mg of bupivacaine 0.25%. Education was uneventful and no opioid antagonisation or muscle relaxant reversal was required. The patient was admitted stable and with good pain control to the intensive care unit and subsequently transferred to the inpatient ward. He was discharged from Role 2E 72 hours after the attack and evacuated to an Afghan military hospital for soft tissue healing and future osteosynthesis.