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FIELD MEDICAL SUSTAINMENT TRAINING Terminal Learning Objectives Reacquaint Corpsmen with basic triage and lifesaving skills. Recognize potential life threatening injuries, treat and prevent shock. In a field environment treat and asses combat casualties and prepare for MEDEVAC. Properly insert and secure an intravenous catheter. TRAIN HARD, FIGHT EASY… AND WIN. TRAIN EASY, FIGHT HARD AND DIE. SHOCK DEFINITION – A state of inadequate tissue perfusion, which causes cellular metabolic oxygen demands to exceed the supply HYPOVOLEMIC SHOCK DEFINITION – A type of shock characterized by an inadequate perfusion of the body due to volume loss within the circulatory system. This is the most common form of shock seen in the combat / field / tactical environment. CAUSES: External loss of whole blood – i.e. hemorrhage Loss of plasma – i.e. severe burns Loss of extra cellular fluids – i.e. gastrointestinal fluids lost through vomiting or diarrhea Internal hemorrhage Third Space losses – fluid moves from vascular system into the tissues, i.e. edema SIGNS / SYMPTOMS Signs and symptoms seen with hypovolemic shock are usually linked with the amount of fluid lost. However, these parameters are only guidelines and should not be taken as absolute amounts. Class I – Initial Stage 1) The circulatory blood volume is decreased but not enough to cause serious effects. 2) Blood volume reduction up to 10% or 3) Clinical Findings (a) No clinical findings approximately 500 cc’s Class II – Compensatory Stage Although the circulating blood volume is reduced, compensatory mechanisms are able to maintain blood pressure and tissue perfusion at a level sufficient to prevent cellular damage Blood volume reduction from 15 – 25% or approximately 750 – 1250 cc’s Clinical Findings Minimal tachycardia (heart rate up to 100 – 105) Slight decrease in blood pressure Mild evidence of peripheral vasoconstriction with cool hands and feet Class III – Progressive Stage or Decompensated Shock At this point, unfavorable signs begin to appear. The body’s compensatory systems can no longer maintain adequate perfusion with the continued blood loss. Blood volume reduction from 25 – 35 % or approximately 1250 - 1750 cc’s Clinical Findings: Tachycardia (heart rate 105 – 120 beats per minute) Decrease in pulse pressure Systolic pressure, 70 – 100 mm Hg Restlessness Increased Sweating Pallor Oliguria (decreased urine output) Class IV – Irreversible Stage Even though the blood volume may be restored and vital signs stabilized, death is imminent Blood volume reduction from 35 to 50% or approximately 1750 – 2500 cc’s Clinical Findings Tachycardia over 120 beats per minute Blood pressure below 60 mmHg systolic and frequently unobtainable by cuff Mental stupor Extreme pallor Cold extremities Anuria (no urine output) TREATMENT: Identify the source of the fluid loss and correct the problem Control gross bleeding – direct pressure, pressure bandaging, pressure points, tourniquets Anti-emetics to control vomiting Anti-diarrhea medications to control diarrhea TREATMENT: Restore intravascular volume Fluid and electrolyte replacement (3 cc’s of a crystalloid fluid (LR, NS) for every 1 cc of blood lost) – available at the BAS. Whole blood replacement – 1 cc of whole blood for every 1 cc of blood lost) Blood Substitute Product replacement – i.e. Hespan. Dosing is 250 - 500 cc’s at a time. Maximum allowable in 24 hours is 1500 cc’s. TREATMENT Elevate lower extremities Trendelenburg positioning Keep the patient warm BURNS Thermal burns are not an uncommon injury on the modern battlefield. They can result from exposure to flame weapons and devices (napalm and white phosphorous), or from explosions from fuel sources (gasoline, diesel, and jet fuel). BURNS The severity of the burns experienced by the patient will vary greatly, depending on the source of the burn, the amount of time the patient was exposed to the agent, and the location of the burn. CLASSIFICATIONS OF BURNS Burns can be categorized by two methods: 1) The depth of the burn 2) Total Body Surface Area (TBSA) affected by the burn First Degree Burn / Superficial Burn Definition – a burn that involves only the epidermis Sign / Symptoms Skin is dry and erythematous Pain to site The burned area blanches with pressure Edema (if present) will be minimal Second Degree Burn / Partial Thickness Burns Definition – a burn in which the epidermis is burned through and the dermis is damaged Sign / Symptoms Deep, intense pain Skin is moist Skin will be hyperemic in color Blister formation Edema will be moderate Third Degree Burn / Full Thickness Burn Definition – a burn in which all the layers of the skin are damaged Sign / Symptoms Skin has a dry, leathery appearance The skin can range in color from pale yellow to cherry red, brown, or carbon black Severe pain around periphery of burn, but little to no pain near center of burn Will see First and Second Degree burns surrounding the Third Degree Burn Total Body Surface Area (TBSA) affected by the burn Burns can be categorized by the percentage of body surface damaged by the burn Two Methods for Estimating the Total Body Surface Area (TBSA) affected by Burns: RULE OF NINES and RULE OF PALMS Rule of Nines (RON) The Rule of Nines divides the TBSA into areas compromising 9% or multiples of 9%, except for the peritoneum which is equal to 1% TBSA. The Rule of Nines is an estimate and is most useful for adults and children over the age of 10 The Rule of Nine’s is helpful for estimating the TBSA of large or regularly shaped burns Rule of Palm’s (ROP) The Rule of Palm’s assumes that the palm size of the patient represents approximately 1% of the TBSA. TBSA is then estimated by approximating the number of “palms” it would take to completely cover the burn The rule of Palm’s is helpful for estimating the TBSA of small or irregularly formed burns TYPES OF BURNS INHALATION BURNS THERMAL BURNS INDUSTRIAL OR CHEMICAL BURNS ELECTRICAL BURNS INHALATION BURNS Definition – burns in the upper and lower airways, caused by the inspiration of heat, toxic, chemicals, smoke, or other gases Cause: 1. Heat inhalation 2. Inhalation of toxic chemicals or smoke 3. Inhalation of carbon monoxide gas Signs / Symptoms Dyspnea Tachypnea Coughing Stridor Hoarseness Sooty Sputum Abnormal Lung Sounds – crackles, wheezes, or rhonchi may be present Signs / Symptoms Burns to the oral and/or pharyngeal mucous membranes Singed nasal hairs Facial burns Tachycardia Treatment Maintain the patient’s ABC’s Adjunctive airways may be used if respiratory distress occurs Endotracheal intubation for severe respiratory distress Emergency cricothyroidotomy if edema causes airway obstruction Administer humidified oxygen if available Place the patient in an upright position Evacuate THERMAL BURNS Definition – tissue injury caused by exposure to extreme radiant heat Causes 1. Scalding liquids 2. Steam or other hot gases 3. Contact with hot objects 4. Fire Sign / Symptoms Signs and symptoms with thermal burns are the same as for First, Second, and Third degree burns Treatment Remove the patient from the source of injury Maintain the patient’s ABC’s Remove any material that could continue the burning process (oils, burned clothing, etc.) First degree burns – immersion in cool water or the application of cool compresses Second degree burns – initially, place in cool water or apply cool compresses. Dry, bulky dressing can be applied later. Administer oxygen therapy if available Protect the patient from heat loss and possible hypothermia Treat for shock INDUSTRIAL OR CHEMICAL BURNS Definition – occur when the patient comes in direct contact with caustic chemical agents Cause: Acids /Alkalies Petroleum Based Products Military Causes: Napalm White Phosphorous Sign / Symptoms Sign / Symptoms are influenced by the length of contact, the concentration of the chemical, and the amount of chemical Erythema Edema Blisters Tissue necrosis Pain at exposure site Treatment Irrigate burned area with copious amounts of water Burns due to concrete or lime should not be irrigated with water. The mixture of these powders with water creates a corrosive substance that will further burn the patient. Brush the powder off the patient instead. Treatment Burns due to phenol (carbolic acid) should not be irrigated with water since phenol is not water soluble. Instead, irrigate with a lipid-soluble solvent (i.e. polyethylene glycol) Hydrofluoric acid burns (used in glass etching, dental laboratories, industry, and electronic plants) are potentially life threatening. Evacuate the patient as quickly as possible White Phosphorous Ignites with air contact – therefore, cover wound with a wet dressing A solution of sodium bicarbonate may be used to rinse the wound to help neutralize the resulting phosphoric acid White phosphorous wounds may be identified by using a fluorescent blue light – the white phosphorous will fluoresce and glow bright white ELECTRICAL BURNS Definition – electrical current, including lightning, can cause severe damage to the body. The skin is burned where the energy enters the body and where it flows into a ground. Along the path of this flow, tissues are damaged due to heat ELECTRICAL BURNS Cause 1. Exposure to electrical current (either AC or DC) 2. Lightning Strike Sign / Symptom Burns where the energy enters and exits the body Difficulty breathing or respiratory arrest Irregular heartbeat or cardiac arrest Muscle tenderness Fasiculations Convulsions Fractured bones Visual difficulties Treatment Maintain the patient’s ABC’s Care for shock Administration of oxygen therapy if available Application of cool compresses to burn areas Dry, sterile dressings to burns Evacuate TREATMENT OF BURNS (GENERAL PRINCIPLES) Maintaining the patient’s ABC’s always takes precedence. Remove the patient from the environment where the burn occurred Remove any substance which will continue to burn the patient Initially, most burns can be irrigated with cool water. Cover with a dry, sterile, bulky dressing Evacuate Immediately st 1 Degree Burn nd 2 Degree Burn rd 3 Degree Heat Injuries HEAT INJURIES Heat Cramps Definition – slow, painful, skeletal muscle cramps and spasms usually in the muscles most heavily used, and last for 1 to 3 minutes Cause – Salt depletion that occurs when fluid losses are replaced by water alone Signs / Symptoms The muscles are tender The skin is usually moist Core temperature may be normal or slightly elevated There is always a history of vigorous activity preceding the onset of symptoms Treatment Rest in a cool environment Drink an oral saline solution (0.9% Normal Saline solution, Gatorade) Rest for 2 –3 days with no exertional activities Heat Syncope Definition – a sudden episode of unconsciousness resulting from cutaneous vasodilation and subsequent hypotension. Cause: Cutaneous vasodilation Hypotension Signs / Symptoms Systolic blood pressure usually less than 100 mm Hg Pulse is weak Skin is cool and moist Core temperature is normal or mildly elevated Treatment Place patient in a recumbant position Rest in a cool place Administration of fluids either by mouth or intravenously Heat Exhaustion Definition – A systemic reaction to prolonged heat exposure (hours to days) and is due to sodium depletion and dehydration Cause: Salt depletion through intense sweating. Prolonged heat exposure. Replacement of body fluids with water and not electrolytes. Signs / Symptoms Thirst Fatigue Nausea Oliguria Giddiness Delirium Gastrointestinal flu like symptoms Signs / Symptoms The skin is moist, flushed Rectal temperature is usually over 37.8 degrees C (100 degrees F) Heart rate is elevated Signs of heat syncope and heat cramps may accompany heat exhaustion Treatment Rest in a cool environment Provide adequate fluid hydration, either orally or intravenously Salt replacement Restriction of activities for the next few days Heatstroke Definition – a severe, life-threatening failure of thermoregulatory mechanisms, resulting in an excessive rise in body temperature Cause: Impaired heat loss mechanisms Signs / Symptoms Core body temperature greater than 41 degrees C (105.8 degrees F) Absence of sweating Loss of consciousness Dizziness Weakness Emotional lability Nausea and vomiting Signs / Symptoms Confusion Delirium Blurred vision Convulsions Coma Skin is hot, flushed, and dry Treatment Maintain an adequate airway and ventilation Rapidly reducing the body core temperature Care must be taken that the cooling methods used do not produce vasoconstriction or shivering which would decrease the cooling rate and increase heat production METHODS OF COOLING THE BODY DIRECT COOLING Items are placed around the body to assist in the dissipation of excess heat Examples include: Applying ice bags to vascular areas of the body (axilla, groin, scalp, and neck regions) Wrapping the body in a cooling blanket IMMERSION Immerse the patient in a bathtub filled with cool room temperature water. Do not immerse the extremities Requires constant monitoring of the patient during the procedure This method is slow (10-40 minutes). May cause hypothermia if the patient is left in the water for too long IMMERSION The use of cold water must be avoided It could cause vasoconstriction, which would impede the rate of heat loss It could cause shivering, which would increase heat production ROOM TEMPERATURE WATER MISTING Spray or mist a semi-nude heat casualty on a mesh hammock applying a film of water on skin A fan may also be utilized to increase the effectiveness of this method Advantages Method is fast (3-10 minutes) Requires minimal monitoring of patient. This method does not require cold or ice water. Ambient air temperature water is all that is required. Can treat multiple casualties simultaneously. EVACUATION Heat stroke patients in a field environment must be medically evacuated to a medical treatment facility. During medevac, douse the patient with water and maintain free movement of air over the wet casualty In an ambulance, leave doors and windows open to promote circulation. In a helicopter, fly at cooler altitudes and leave doors open, if possible EVACUATION Sedative drugs should be avoided because they disrupt an already malfunctioning heat regulating mechanism. If convulsion occurs, Valium may be administered intravenously RESPIRATORY TRAUMA AND DISORDERS Rib Fractures Definition – a break in the integrity of any of the rib bones Causes: Blunt trauma to the rib cage Crushing injuries to the chest Signs / Symptoms Pain at the site Pain with inspiration / exhalation Shortness of breath Deformity Crepitus Subcutaneous emphysema Ecchymosis Treatment Place patient on affected side Pain medications Simple fractures of 1 to 2 ribs usually require no more treatment Multiple fractures can be immobilized with a sling and swathe. Oxygen therapy if available Encourage coughing and deep breathing to prevent atelectasis Flail Chest Definition – when many ribs are fractured, especially at multiple sites, a portion of the chest wall may become mechanically unstable. When negative intrathoracic pressure is developed during inspiration, the unstable (flail) segment moves inward and reduced the amount of air taken in Causes Blunt trauma to the chest wall Signs / Symptoms Pain with respirations Paradoxical chest wall movement Dyspnea or respiratory distress Treatment Administer oxygen if available Endotracheal intubation – if respiratory condition deteriorates Administer analgesics (morphine may be given for this condition) External chest wall supports (taping, binding) are not required and may be harmful to the patient Pneumothorax Definition – a collection of air in the pleural space which causes the lung to collapse Causes: Penetrating trauma – from either chest wall injury or abdominal injuries that cross the diaphragm Blunt trauma Spontaneous causes Signs / Symptoms Sudden, sharp chest pain Difficulty breathing Decreased chest wall motion Tachypnea Tachycardia Diaphoresis Signs / Symptoms Hypotension Hyper-resonance with percussion on affected side Absent or diminished breath sounds on affected side Pallor or Cyanosis Treatment Place patient in Fowler’s position Administer oxygen if available Analgesics Needle thoracentesis if symptoms are severe If caused by a wound, applying an occlusive dressing to the site Evacuation Hemothorax Definition – an accumulation of blood and fluid in the pleural cavity, between the visceral and parietal pleura Causes: Penetrating trauma to the chest wall, great vessels, or the lung Blunt trauma (less common) Signs / Symptoms Chest pain Difficulty breathing Decreased chest wall motion Tachypnea Tachycardia Hypotension Dullness on percussion to affected side Diminished or absent breath sounds on affected side Treatment Place patient in Fowler’s position Administer oxygen if available Analgesics (aspirin and motrin should be avoided because of their anti-thrombolytic actions) Chest tube insertion to remove the accumulated blood (if at BAS or higher echelon of care) Insertion of two large bore IV’s Evacuation Hemopneumothorax Definition – an accumulation of air, blood, and fluid with in the pleural cavity, causing the lung to collapse. Causes: Penetrating trauma to the chest wall, the great vessels, or the lung Signs / Symptoms – same as for hemothorax and pneumothorax Treatment Place patient in Fowler’s position Administer oxygen if available Analgesics Endotracheal intubate if signs/symptoms become severe Chest tube insertion to remove accumulated air, blood, and fluids (if at BAS or echelon of care) Two large bore IV’s Evacuation Tension Pneumothorax Definition – is a life threatening lung injury. Air enters the pleural space on inspiration, but the air cannot escape on expiration. Rising intrathoracic pressure collapses the lung on the affected side causing a mediastinal shift that compresses the heart, great vessels, trachea, and ultimately, the uninjured lung. Venous return is impeded, cardiac output falls, and hypotension results. Causes Open chest injuries Closed chest injuries Signs / Symptoms Signs of pneumothorax with worsening symptoms Distended neck veins Tracheal deviation – a shift towards the unaffected side Treatment Cover the open wound with an occlusive dressing sealed on three sides Needle thoracentesis Administer oxygen therapy if available Administer analgesics Two large bore IV’s Chest tube insertion (if at a BAS or higher echelon of care) Open Pneumothorax or “Sucking Chest Wound” Definition – a pneumothorax resulting from a wound through the chest wall. Air enters the pleural space both through the wound and the trachea. Causes: Large, penetrating trauma to the chest wall Signs / Symptoms Sudden chest pain Dyspnea Difficulty breathing Decreased chest wall motion Hypotension Tachycardia Tachypnea Open sucking wound on inspiration Diminished or absent lung sounds on affected side Treatment Cover the wound with an occlusive dressing. Needle thoracentesis may be indicated to correct the pneumothorax if signs or symptoms are severe. Administer oxygen if available. Administer analgesics Two large bore IV’s Evacuation EMERGENCY CRICOTHYROIDOTOMY DEFINITION – An emergency surgical procedure where an incision is made through the skin and cricothyroid membrane which allows for the placement of an endotracheal tube into the trachea when airway control is not possible by other methods INDICATIONS FOR EMERGENCY CRICOTHYROIDOTOMY Obstructed airway – an obstructed object will usually prevent the passage of an endotracheal tube through the airway. Therefore, a surgical airway distal to the obstruction is required. Causes of an obstructed airway include Trauma to the head and neck which would preclude the use of an ambu-bag, oropharyngeal airway, nasopharyngeal airway, and endotracheal tube insertion CONTRAINDICATIONS FOR CRICOTHYROIDOTOMY Massive trauma to the larynx or cricoid cartilage – damage to the affected structures will make it impossible to perform the procedure properly Contraindicated if another means of establishing an airway have not been attempted (i.e. nasotracheal or orotracheal intubations) COMPLICATIONS ASSOCIATED WITH CRICOTHYROIDOTOMY HEMORRHAGE ESOPHAGEAL PERFORATION OR TRACHEOESOPHAGEAL FISTULA Definition – the creation of a hole between the esophagus and trachea Causes: Creating an incision too deep through the cricothyroid membrane Forcing the endotracheal tube through the cricothyroid membrane and into the esophagus Treatment requires surgical repair at higher echelon of care