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Wilderness Trauma Assessment and Equipment

Wilderness Trauma Assessment and Equipment. Dr. Albert R. Wheeler, MD Medical Director GTNP Medical Director TCSAR. Disclosures. I wish I had some financial affiliation to some of the products that we will talk about...but I don’t.

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Wilderness Trauma Assessment and Equipment

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  1. Wilderness Trauma Assessment and Equipment • Dr. Albert R. Wheeler, MD • Medical Director GTNP • Medical Director TCSAR

  2. 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

  3. 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.

  4. 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

  5. What is Wilderness? • An evolving definition in regards to EMS and Medicine • Backcountry • Sidecountry • Urban Areas?

  6. 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

  7. Definition of Wilderness Medicine • The practice of resource-limited medicine in austere environments.(SAEM Website)

  8. Examples

  9. 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)

  10. How Would you care for this patient Here?

  11. How about Here?

  12. And Here???

  13. 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

  14. Wilderness Airway Management Options • Endotracheal Tube • Supraglottic Airway • Oral Airway • Nu Mask/BVM • Nasal Airway

  15. Laryngoscope • Traditional Larygoscope: • Heavy • Battery Hog • Bulbs burn out • TruLite • Disposable with Metal Blade • Uses LED light • Long Battery Life • Weighs 4.2 oz

  16. Digital Intubation

  17. 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

  18. NuMask (IOM) • Intra-oral Mask • Rescue Applications • Small • Ventilate in any position • Single Provider Ventilation • Avoids problems with “facial seal”

  19. Airway Improvisation

  20. Improvised Cric

  21. Alternative Cric

  22. Wilderness Breathing Assessment and Management • Eco Challenge 2000 Borneo • Racer crashes on bike leg of race • Impaled on tree branch • Semiconscious in respiratory distress

  23. 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.

  24. Breathing Assessment and management • Hypoxia • Flail Chest • Pneumothorax • Tension Pneumothorax

  25. Oxygen • Standard D Cylinder • 425 Liters • 5lbs • Carbon Fiber DD Cylinder • 717 Liters @ 3000psi (533 Liters @ 2000psi) • 3.7lbs

  26. Oxymizer • An Oxygen conserving device • Offers up to 4:1 Oxygen Savings • Can Extend the Duration of Oxygen Cylinder • CHAD Therapeutics

  27. Extended Duration

  28. Flail Chest

  29. Cyclone BVM • Disposable Single Pt. Use BVM • Vacuum sealed for low profile • Oxygen flows into mask • Manufactured by North American Rescue, LLC

  30. Pneumothorax • Open Pneumothorax • Occlusive Dressing on 3 Sides • Pre-Packaged Chest Seal Products • Tension Pneumothorax • Needle Decompression • Cook Ptx Kit • NAR ARS Needle

  31. Open Pneumothorax • Traditional Treatment is 3 sided occlusive dressing • Do you carry the supplies for this? • Time consuming to produce

  32. Asherman Chest Seal • One Way Valve • Adhesive allows application even over chest hair • Quick and Time saving

  33. Bolin Chest Seal • Triple Valve Design • Jell-Based Adhesive • Can be removed and replaced

  34. 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.

  35. Thoracostomy Kits • Needle Thoracostomy Kits • Longer Needles • Cook Kit • Comes with Valve • 15g X 6cm Needle • NAR = 14g X 3.25in (7cm) Needle

  36. Improvised Flutter Valve

  37. 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”.

  38. 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

  39. Bleeding in the Wilderness • Major Advances because of Trauma care of wounded soldiers • “traditional measures” • Tourniquets • Hemostatic Agents • Vascular Access

  40. Direct Pressure • Pinpoint Pressure • What about pressure bandages? • Pressure Points • Pressure = F/A

  41. Tourniquets • Tourniquets are Good! • If applied Correctly and in the right situations. Doyel et al, PREHOSPITAL EMERGENCY CARE 2008;12:241–256

  42. Tourniquet Use Cont. Doyel et al, PREHOSPITAL EMERGENCY CARE 2008;12:241–256 Doyel et al, PREHOSPITAL EMERGENCY CARE 2008;12:241–256

  43. Hemostatic agents

  44. Vascular Access • IV • Hard to obtain in wrong environment • Affected by Vascular Volume (i.e. Shock) • IO • Quick • Reliable • Relatively Painless?

  45. 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”

  46. 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???

  47. Wilderness Fluid Warmers

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