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

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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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