First, the pictures version:
.. and then a few words:
Trauma in remote places. I Rogers, UWA.
The standard approach to the emegency management of severe trauma assumes the presence of other staff, equipment and support in an optimal hospital environment. The immediate management of trauma in wilderness settings requires improvisation and lateral thinking.
Special environments result in additional challenges: hot & dry v hot & humid, cold & wet v cold & dry; hyperbaric or high & cold.
Injury rates are lower than expected for expeditions e.g. around 1 in 1000 participant days for major trauma, traumatic deaths being rare.
Wilderness Medical Society defines WM as medicine in a remote geographic environment more than 1hr from definitive meeical care. It is limited by medical gear that can be carried, therefore technology limited or ‘medicine stripped bare’. Examples include disaster relief, Qantas flight over Antarctica, road trauma in rural WA.
- A: airway. endotracheal intubation = gold standard for a definitive airway but requires direc vision & optimal access during procedure. Sunlight & limited access make endotrahceal intubation difficult. laryngoscopes can fail, may be poorly tolerated. Laryngeal mask can be used in some remote settings as substitute. No direct vision needed, better tolerated but does not provide definitive airway. A safety pin has been used to anchor the tongue in order to protect airway.
- B: breathing. self-inflating bag, but bulky and not always available. pocket mask = useful standby. Plastic cannula for conversion of tension pneumothorax to simple pneumothorax.
- C: circulation. iv fluids = best practice, used aggressively. emphasis shifting to permissive hypotension in some settings. fluids essential in battlefield management of blood loss
- D: disability. best practice = cervical immobilisaion with collar & spinal board. down side = difficult intubation risk of aspiration, breathing impairment, pressure sores & discomfort. In remote locations can’t walk & evacuation may be delayed. debate over best rules to apply for clearing C-spine. May be necessary to improvise spinal immobilisation with available materials.
- E: exposure. no imaging available for assessment of injuries. small ultrasound scanners available. may be suited to wilderness settings for FAST scan.
- Others: ketamine used in remote locations, though risk of dissociation; acute management of tension pneumothorax can be life saving, thoug occurrence not common; shoulder dislocation = limiting injury on expedition – practical ways of reduction for remote locations.
MicroGnome as at 16:45, 5-DEC-10.