Wilderness Trauma Assessment and
Equipment
Wilderness Trauma Assessment and
EquipmentDr. Albert R. Wheeler, MD
Medical Director GTNPMedical Director TCSAR
Dr. Albert R. Wheeler, MDMedical Director GTNPMedical Director TCSAR
Disclosures
• I wish I had some financial affiliation to some of the products that we will talk about...but I don’t.
• I am an active volunteer on TCSAR and Medical Director of GTNP EMS
Objectives
• To understand Wilderness Medicine Decision Making in Trauma.
• And why it is important to front country EMS
• To review techniques and equipment useful in the wilderness setting.
Wilderness Medicine Training
• This talk is NOT a comprehensive review of delivering Wilderness Trauma Care
• There are many companies providing courses in this
• WMA, WMI, NOLS, SOLO, etc...
• WALS, WEMT, WFR
What is Wilderness?
• An evolving definition in regards to EMS and Medicine
• Backcountry
• Sidecountry
• Urban Areas?
How does Wilderness Differ from Everyday
• Extreme Environmental Conditions
• Little or no Resources
• May require technical extrication
• May require covering long distances without motorized assistance
Definition of Wilderness Medicine
• The practice of resource-limited medicine in austere environments.(SAEM Website)
Examples
Wilderness Airway Assessment and
Management
• 35 y/o Male biker injured after going off of a jump.
• Was Helmeted but Helmet is fractured.
• GCS 6 (E = 1, V = 2, M = 3)
How Would you care for this patient Here?
How about Here?
And Here???
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Wilderness Airway Considerations
• Benefit Vs. Risk of Elevated ICP
• Patient’s GCS/Resp. Rate
• Distance of Extrication
• Oxygen Requirement
• Need to “Bag” the patient
• Technical Aspects of Extrication
Wilderness Airway Management Options
• Endotracheal Tube
• Supraglottic Airway
• Oral Airway
• Nu Mask/BVM
• Nasal Airway
Laryngoscope
• Traditional Larygoscope:
• Heavy
• Battery Hog
• Bulbs burn out
• TruLite
• Disposable with Metal Blade
• Uses LED light
• Long Battery Life
• Weighs 4.2 oz
Digital Intubation
King LTD Airway
• Disposable Supraglottic Airway
• Easy to Insert with little head movement
• Less Laryngeal Stimulation
• As Secure as ETT but not definitive airway
• Less complicated than Combitube
NuMask (IOM)• Intra-oral Mask
• Rescue Applications
• Small
• Ventilate in any position
• Single Provider Ventilation
• Avoids problems with “facial seal”
Airway Improvisation
Improvised Cric
Alternative Cric
Wilderness Breathing Assessment and
Management
• Eco Challenge 2000 Borneo
• Racer crashes on bike leg of race
• Impaled on tree branch
• Semiconscious in respiratory distress
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Wilderness Breathing Considerations
• Assessment of Breathing can be difficult in windy or cold environments
• A stethoscope is not always necessary as a tactile assessment can and should be preformed.
• Supporting Breathing over long extrication with a BVM can be problematic
• Providing oxygen support over long durations typically requires lots of supplies (O2 bottles)
• May need to carry specific supplies for procedures.
Breathing Assessment and management
• Hypoxia
• Flail Chest
• Pneumothorax
• Tension Pneumothorax
Oxygen
• Standard D Cylinder
• 425 Liters
• 5lbs
• Carbon Fiber DD Cylinder
• 717 Liters @ 3000psi (533 Liters @ 2000psi)
• 3.7lbs
Oxymizer
• An Oxygen conserving device
• Offers up to 4:1 Oxygen Savings
• Can Extend the Duration of Oxygen Cylinder
• CHAD Therapeutics
Extended Duration
Flail Chest
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Cyclone BVM
• Disposable Single Pt. Use BVM
• Vacuum sealed for low profile
• Oxygen flows into mask
• Manufactured by North American Rescue, LLC
Pneumothorax
• Open Pneumothorax
• Occlusive Dressing on 3 Sides
• Pre-Packaged Chest Seal Products
• Tension Pneumothorax
• Needle Decompression
• Cook Ptx Kit
• NAR ARS Needle
Open Pneumothorax
• Traditional Treatment is 3 sided occlusive dressing
• Do you carry the supplies for this?
• Time consuming to produce
Asherman Chest Seal
• One Way Valve
• Adhesive allows application even over chest hair
• Quick and Time saving
Bolin Chest Seal
• Triple Valve Design
• Jell-Based Adhesive
• Can be removed and replaced
Needle Thoracostomy
• What do you carry for Needle Thoracotomy?
• Needle Thoracostomy: Implications of Computed Tomography Chest Wall Thickness:ACADEMIC EMERGENCY MEDICINE 2004; 11:211–213.
• Results: The mean chest wall thickness in the patients studied averaged 4.24 cm (95% confidence interval [CI] = 3.97 to 4.52). Nearly one fourth (25) of the study patients had a chest wall thicker than 5 cm. Women, on average, have thicker chest walls than men (4.90 for women; 4.16 for men; p = 0.022).Conclusions: In this study, a catheter length of 5 cm would reliably penetrate the pleural space of only 75% of patients. A longer catheter should be considered, especially in women.
Thoracostomy Kits
• Needle Thoracostomy Kits
• Longer Needles
• Cook Kit
• Comes with Valve
• 15g X 6cm Needle
• NAR = 14g X 3.25in (7cm) Needle
Improvised Flutter Valve
Wilderness Circulation Assessment and
Management
• 20 something “Extreme Skier”
• Falls out of bounds and hits head on rock.
• Bleeding profusely from scalp!!!
• Buddies call for help. Say he is pale and “Really bleeding...Dude”.
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How do we evaluate SHOCK and Bleeding in the Wilderness
• SHOCK
• A clinical Diagnosis Not Dependent on Blood Pressure
• Check Pulses (peripheral Vs. Central)
• Blood Sweep to identify sites of bleeding
Bleeding in the Wilderness
• Major Advances because of Trauma care of wounded soldiers
• “traditional measures”
• Tourniquets
• Hemostatic Agents
• Vascular Access
Direct Pressure
• Pinpoint Pressure
• What about pressure bandages?
• Pressure Points
• Pressure = F/A
Tourniquets
• Tourniquets are Good!
• If applied Correctly and in the right situations.
Doyel et al, PREHOSPITAL EMERGENCY CARE 2008;12:241–256
Tourniquet Use Cont.
Doyel et al, PREHOSPITAL EMERGENCY CARE 2008;12:241–256
Doyel et al, PREHOSPITAL EMERGENCY CARE 2008;12:241–256
Hemostatic agents
Vascular Access
• IV
• Hard to obtain in wrong environment
• Affected by Vascular Volume (i.e. Shock)
• IO
• Quick
• Reliable
• Relatively Painless?
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IO Devices
• Handheld Needle
• Can be unstable
• More difficult to place (except in infants)
• EZ IO
• Used by military
• Long Battery Life
• Easy to place in adults and Children
• BIG Device
• “Bone Injection Gun”
• Automatic and Spring loaded
• Separate Pediatric and Adult “guns”
Wilderness Fluid Administration
• What is the GOAL of fluid therapy
• Normal Vitals (blood pressure?)
• Improved Vitals (blood pressure?)
• Improved Clinical Picture?
• Do we have different goals in Trauma?
• Potential Problems with Wilderness IVF
• Keeping fluid warm and unfrozen
• Solution???
Wilderness Fluid Warmers
Wilderness Evaluation and Assessment of Deficit and Exposure
• Immobilization can greatly increase time of extrication from wilderness
• When appropriate clearing the C-spine should be done using approved protocols
• Exposure of patients in the Wilderness is potentially harmful because of the environment
• Minimize exposure
• Insulate and Warm patient as much as possible
• Hypothermia is Deadly in Trauma
=
Summary
• You may not go to the Wilderness But the wilderness may come to you...prepare for it
• Good BLS care often is all that is required - Appropriate Direct Pressure
• Appropriate specialized equipment can be very useful but sometime you will have to improvise... Be creative.
Final Thought
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