Transcript the Wilderness ALS Equipment and Care Presentation

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.
• 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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