2. Welcome to the Expedition and Trauma Teaching Weekend
As we are sure mostof youknowwe are a group of fourthyear medical
studentsluckyenoughtoundertake asix weekprojectinWilderness
Medicine. We feel we learntsome useful skillsandhada great time and
we wouldlike toshare boththe skillsandthe funwithyou. We are going
to be coveringlotof informationwithyouthisweekendsowe thought
that itwouldbe useful togive youa handoutwithsome of this
informationsoyoucan checkoverthingsoverthe nextcouple of days
and recapwhenyouget back home.
Duringthisweekendwe wanttochallenge youso we are goingto
simulate some traumasenariosinwhichyouwill have tomanage some
verysickpatients. Don’tbe alarmed! These senariosare justa chance for
youto learn-weatheritslearningthatitcanbe hard to knowwhatto do,
a chance to practice yournewskills,ora chance to practice teachingand
sharing your skillswith others. Everybodyonthisweekendhasa
differentbackground,some have hadfouryearsof medical educationand
have undertaken SSCsrelatedtotrauma. Othersdon’tstudymedicine at
all. Whateveryourbackgroundthisisa chance to practice workingas a
teamso ask us butask each othertooand if you see someone lookingfor
helpsupportthem. Afterall teachingisone of the mostdifficultskillsto
masterand one of the bestwaysto consolidate yourownleaning!
From all of us inthe teachingteamwe are so excitedaboutgettingto
knowyouthisweekend. We hope itishelpful andgivesyouabitof an
insightintoexpeditionmedicine. If youhave anyproblemsatall please
chat to any of us. Most of all we hope youhave fun!
Timetable (all timingapproximate)
Sat – am PrimarySurveyTeaching
Demonstration(10min)
ABC...teachingfromus(1hr)
*Break*
Teachingeachother(1hr)
Group practice (1hr)
*Lunch*
pm Workshops(3x45 min) Breakbetweenthe 2nd
and3rd
Sun– am Demonstration(10min)
Team games(1hr)
A walkwithmanyaccidents (3hrsinc lunch)
3. Before we startthinkingabouthowwe can manage trauma patients itis
importantto rememberthatourfirstpriorityis alwaystoinsure ourown
safety. Oursecond isensuringthe safetyof the unaffectedmembersof
our party. Gettingourselvesin todangerwill onlymake the situation
worse. Arrivingatthe scene of an incidentiscan be confusingand
alarming,especiallyif thereismore thanone injuredparty. There isa
useful neumonictoremindustokeepsafetyinmindandkeepa good
overviewof the taskat hand....
SAFETAC – A great frameworkwhichcanbe adaptedto all trauma
situations
S - Shout for Help
A - Assessfor danger
F - Findand remove danger/Findother casualties
E - Evaluate Casualties
T - Triage
A - AssessCasualties
C - Communicate
Primary Survey
Thisis a succinctinitial assessmentof yourpatientdesignedtofindany
life threateninginjuriesthatrequire immediate treatment.
C – Can yousee an obvious ‘catastrophic’haemorrhage from a limb? If
so youshouldtryand applyindirectpressure ata pulse pointabove the
site andthenapplya tourniquetabove the bleedtostemthe bleeding
before carryingonwithyourABC assessment.
A for Airway
‘A’ of ABC because any problems will be rapidly fatal if no action taken-
therefore airway needs assessment first.
Remember not to forget ‘SAFET’ of ‘SAFETAC’ before diving into the
primary survey! (Shout/Send/Signal for help; Assess safety; Free from
hazards/Find other casualties; Evaluate casualty i.e. rapid ABC; Triage).
Assessment
Aims;
1. Is there a problem with your casualty’s breathing?
2. What’s causing the problem?
Response
“Hello,are youok? Can youhearme?” isa goodquickcheckyour casualty
isnot asleep!
If the patientcanspeak,theirairwayis PATENT. If theyare strugglingto
speak,itmay be AT RISK.
If the patientisresponsive (i.e.conscious),withanairwayproblem,they
will be inthe bestpositionfor their airway. Donot move thembutassess
themas below,asbestyoucan. If the patientisunresponsive…
Feel and Listen
Put yourcheekbytheirmouth/nose andhandontheirchest:isair
movingin/out,isthe chestrising/falling.
4. If NO AIR isbeingmovedorthere is NOISY BREATHING…
(Noises;gurgling,stridor*,snoring)
Look
Is the airway OBSTRUCTED? Openthe mouthand lookforobstruction.
Look forcyanosisand chestmovements –cluestoadequate air
movement.
Common airway problems Presentation
1. The casualty’s tongue –
tongue slips back into
throat,seenin head injuries
or decreased consciousness
Snoring
2. Foreign body (FB)
a. Vomit
b. Blood
c. Solid object
d. (e.g. dentures)
Gurgling
(espif bloody)
3. Trauma
a. Jaw
b. Neck
c. Facial
Gurgling
(espif liquidFB)
Less common airway problems
4. Trismus - tightlyclosed jaw,
seen in epilepsy
5. Angioedema – swelling of
the throat tissue, seen in
severe allergic reactions,
burns and smoke inhalation
Stridor*,snoring
6. Infection e.g. epiglottitis Stridor*,drooling
If you can hear wheeze,thisisasignof lowerrespiratorytract
constriction,notanairwayproblem.
*stridoris an unmistakablehigh-pitchedwheeze,mainlyoninspiration
Treatments
Manouvres
The firstinterventionforairwayproblems.The aimistorepositionthe
softtissuesof the oropharynx (suchasthe tongue) tomaximise the
airwayopening.Twomainapproaches:
Jaw thrust
Veryuncomfortable!Soonly
goodif consciousnessreduced.
Jaw thrustisgood because it
minimisesc-spinemovement- if
fracture of the cervical spine isa
possibilityheadmustbe
stabilisedfrompointof contact
withcasualtyand youshould
NOT performahead tiltchinlift
Head-tiltchin-lift
5. 2 stage manoeuvre. Seems
simple but requires practise to
be effective!
The recovery positioncan alsobe utilisedtoaiddrainage of blood,vomit,
mucousor saliva.(mechanical SUCTIONINGmayalsobe carriedout for
thispurpose- mustbe careful notto insertsuctioncathetertoofar).
Oxygen
If available,administerit!Especiallytherapeuticforcasualtieswith
breathing,headorcirculatoryinjuries.
Adjuncts
Usedin addition tomanoeuvres.Generallyif availabletheyare worth
usingas provide increasedairwaypatency.Importantpointsare that
NPAs(nasopharyngeal airways)are the besttoleratedadjunctin
semiconsciouscasualties,whilstOPAs(oropharyngeal airways) keepthe
tongue inplace better.Bothcarry a riskof bleeding,softtissue injuryand
inducinggaggingorvomiting.
Laryngeal maskairways(LMAs) and I-Gelsare other‘supraglottic’typesof
adjunctwhichlie more directlyoverthe larynx.
Surgical airway
Last resort!Carriedout as eitherneedle orformal cricothyroidotomy.
Formeriseasiestbutlastsonlyfor45 mins,whilstlatterrequiresscalpel
and tracheostomytube.Entrytotrachea throughCRICOTHYROID
MEMBRANE- depressioninferiortoAdam’sapple.
B for Breathing
Aimsof PrimarySurveyBreathingassessment:
1) Is breathingpresentornot?
2) If presentisbreathingabnormal?
3) If presentisthere animmediatelylife threateningproblem?
‘FLAP TWELV’mnemonic:
Feel – respiratoryrate,chestexpansion,(symmetry,) downthe ribs,
‘raking’forholes
Look – wounds,symmetry,flail chest,cyanosis
6. Auscultate + Armpits – air entry(same on bothsides?/crackles), feel and
lookat armpitsfor wounds
Percussand pat the back – ensure youpercussvital areas(2 each side),
rake back for wounds
Trachea – central or not (rememberdeviationisalate sign)
Wounds– feel andlookaroundneck
Emphysema – feel neckandabove collarbone for‘bubble wrap’
Laryngeal crepitus- feel larynx forinstability
Veins – distended?(considermaynotbe distendedif hypovolaemic
though)
Pneumothorax - Asymmetricalchest,Percussion= resonant,Breathing
sounds= reduced/ absent,deviatedtrachea(latesignin tension
pneumothorax).Cannula2nd
intercostalspace.
Suckingchest wound(‘open pneumothorax’) - dyspnoea,openwoundin
chest wall,reduced breathsoundsonside affected,surgicalemphysema.
Asherman’schestseal.
Haemothorax– percussiondull,visible bruising,labouredbreathing,
deviation of trachea(late andsevere),breathsoundsreduced,signsof
shock. Evacuate!
Flail chest – paradoxicalbreathing,severebreathlessness,guarding,signs
of shock.Splint.
C for Circulation
Pulse - The normal pulse rate inadultsis 60-100 (children’sheartsbeata
little faster)
Tachycardia (afast pulse) mayindicate bloodloss. Heartrates (HR) can
alsorise due to painand anxiety. (HRalsorisesinothertypesof shock,
hypovolaemicshockisthe mostlylikelyformof shocktoencounterina
trauma setting)
Bradycardia(a slowpulse) canbe a late signof bloodloss,i.e the patient
has lostso muchbloodthe bodyis nolongertryingto keepthe blood
pressure upbypumpingfaster. Inthissituationthe pulse mayfeel weak.
Pulse ratescan normallybe lowinyoungfitindividuals.
The pulse can alsogive youan indicationof the patientsbloodpressure.
If you can feel there radial pulse therebloodpressure will be >80 systolic.
If you can’t feel the radial butcan feel the femoral theresystolicis
roughly<80 and >70. If youcan onlyfeel there femoral theresystolicis
roughly<70 and >60.
Central Capillary Refill Time (CRT) – Feel this bypressingdownwitha
fingeronto the sternumfor5 secondsandthenreleasing. Normally
bloodreturnstothe small capillariesturningthe skinpinkagaininunder
2 seconds. If thisisdelayeditindicatescirculatoryfailure. One cause of
thisisbloodloss. In coldconditionsCRTcan be prolongednormally,itisa
more accurate measure of circulatorystatusinwarm environments.
Blood losscan be venousorarterial. Arterial bleedsspurtandare bright
red. Bloodis lostmore quicklyanditis more difficulttostopthe
bleeding. If yourpatienthasan external arterial bleedinalimbapply
directpressure ata proximal pulsepoint,applyatourniquettothe thigh
or upperarm, and raise the limb. Venousbleedsooze andare darker.
7. Applydirectpressure withthe palmoryourhand (preferablywithsterile
gauze) tovenousbleedandarterial bleedsof the trunk. Bandage asbest
youcan.
Bleedingmightnotbe immediatelyobvious,checkthourgherlyfor
bleedingespeciallyif the patientseemsclinicallyshocked. Remember
waterproof clothingmaydisguise ableed.
Visiblebloodlossthroughaskinlesionisjustone wayinwhichthe
circulatorysystemcanloose blood. Bloodcanalsoleakintointernal
cavities. A wayor rememberingthisis‘Bloodonthe floorand four more’
The 4 more are;
Abdomen Thorax Long bones Pelvis
You can loose litresof bloodintoall these bodycavities.
Palpate the abdomenandlongbonesassessingforswelling,bruisingand
tenderness. Percussthe Thorax (bloodwillproduce astonydull sound),
and pressGENTLY on hipsassessingpelvicstability(be careful,pushingto
hard on a fracturedpelviscanincrease the damage).
It issometimesdifficulttoknowwhenapersonisbleedinginternally,
especiallyinthe absence of anobviousinjury.Insome casesinternal
bleedingisindicatedbythe presenceof bloodinthe vomit,stool,or
urine,orby coughingupblood.Symptomstowatchfor include feelingsof
anxietyandlightheadedness;fainting;dilatedpupils;cold,clammyskin;
paleness;rapid,shallowbreathingand shortnessof breath.
In mostinstances,there are nofirstaidtechniquesforstoppingsevere
internal bleeding. Evacuationisyourpriority. Longbonescanbe splinted
reducingthe space inwhichbloodwill pool (thisshouldreduce painas
well).
In the unlikelyeventthatyouhave fluidswithyougive themonlywhen
your patientloosesthereradial pulse(thisis onlythe case ina wilderness
setting!). If yoususpectyoumayhave to do this cannulate pre-emptively
and waitas thiswill become more difficultasthe BP drops.
D for disability
Level of consciousness:AVPU
◦ A = alert
◦ V = response to voice
◦ P = responds to pain
◦ U = unresponsive
Pupils:size,symmetryandreactiontolight
Neurological:checkforweaknessineachlimb/cansqueezefingersand
move toes
Bloodglucose level:DEFG(Don'tEver ForgetGlucose)
E for Exposure and Environment
It isimportantto exposure the patienttocomplete afull examination.
In a wildernesssettingitisusual toonlyexpose one partof the patientat
a time to limitheatloss.
Lookfor:
◦ life-threateningskinrashes(non-blanchingrash)
◦ bruising
◦ otherwounds(bee stings,puncture wounds)
◦ medi-alertbracelets,tags
Checkpatient'stemperature (thermometerorcompare against
yourself)
8. If too coldthinkhypothermia:
▪ reduce heatloss
▪ insulate fromweatherandground
▪ do nottry and warm extremities(byrubbingorheat
packs) as it drawsbloodfromessential organs
▪ whengivingfluids,warmthem
If too warm thinkheatexhaustion/stroke (rememberthiscan
occur evenincoldconditions)
▪ remove clothing
▪ sponge downwithluke warmwater
▪ small sipsof cool drinks
▪ IV fluids
Shelterthe casualtyfromwind,rainorsun usingnatural shelterora
groupshelter.
Secondary Survey
Aiming to find EVERY injury before handover;
Head & skull (inc. eyes
and ears)
GCS, Basal skull fracture (mastoid
bruising (battle’s sign), CSF from
ear, periorbital bruising (racoon
eyes))
Maxillofacial
Evidence of fracture/burn/other
injury
Cervical spine & neck Repeat TWELV, check c-spine for
tenderness, consider clearing it
(NEXUS or Canadian rules)
Chest
FLAP: feel, look, auscultate,
percuss. Inc back.
Abdomen
FLAP: Feel for tenderness (!liver,
spleen), look, auscultate, percuss.
Pelvis
Gently press for instability, look for
injuries.
Perineum
Bloodat the external meatusor
scrotal bruisingsuggestsurethral
injury;attemptstocatheterise the
patientmayworsenthis.
Orifices (e.g. rectum)
PR if pt may have spinal injury
(tone) or abdo/pelvic injury. High
prostate = urethral injury.
Neurological
Tone,reflexes,power,co-ordination,
sensation.
Musculoskeletal
Look, feel, move, ALL joints and
bones intact and function nml.
Active before passive. Carry out
before neuro as may masquerade
as neuro problem. If splint, check
9. pulse and sensation distally.
Definitive care plan
(inc evacuation)
Because we love pneumonics here’s one to help you remember the
secondary survey....
Has My Critical Care Assessed Patient’s Priorities Or Next
Management Decision.
Some of these are not so easy on the side of a crag / stuck in a cave
etc – record what you DID NOT DO and make sure you hand this
over too, or complete it ASAP.
ETHANE Report - A good wayof communicatingyoursituationandneeds
to the emergency services. If anambulance can’treach youcall the
police insteadandaskformountain rescue.
E – Exact Location
T – Type of incident
H – Hazards
A – Access
N – Numberof casualties
E – Equipment/Emergencyserviesonseenand required
The TRIAGE Sieve - Used whencasualties overwhelmmedical resources.
Aim– Do the bestforthe most,prioritiespatientcare andhelps
evacuationplanning.
KEEP A RECORD CRT IS UNRELIABLE INTHE COLD
AMPLE History – A focusedhistory to take in a trauma situation,part of
the secondarysurvey
Allergies
Medication
Past Medical History
10. Last ate (useful foranaestheticuse andneverforgetglucose!)
Event
MIST Report - A succinct way of explainingtoemergencyserviceswhat
has happenedwhenthey arrive on scene
Mechanismof Injury
Injuriessustained
Signs
Treatment
Example – Thisis JohnSmith,he fell off a6 foot wall onto his rightleg.
He has a suspectedfracture of the rightleg,a possible fracturedankle
and a large graze to the skinof hisleg. His leg (bellowthe knee)was
malalignedonarrival andwascausinghimconsiderable pain. Hisankle
pulse wasabsent,he wasable to feel andmove histoes. There wasa
small amountof bloodlossfromthe graze. We extendedandsplinted
hisleg,sprayedthe graze withan antisepticsprayandgave him1g of
paracetamol.
