Prolonged field care

Sometimes it is not possible to evacuate casualties promptly - care "in the field" becomes prolonged beyond the primary survey/resuscitation & secondary survey phases.

As with many other parts of wilderness medicine, a structured approach is likely to reduce the risk of omitting important aspects of casualty care.


A FIT ARSE

This mnemonic covers aspects of clinical care needed in prolonged casualty care:

A

ask the casualty how they are



F

fluids:monitor urine output and ensure input & output are adequate
I

infection: keep wounds clean and consider early antibiotics
T

tubes: ensure they are working and that they are kept clean



A

analgesia
R

records: write down your findings, actions and observations
S

sanitation: you need to deal with the casualty's faeces and urine
E

environment: do whatever possible to prevent environmental factors (e.g. cold) worsening the casualty's condition

Ask the casualty/patient how they are

Sounds obvious, but omitted surprisingly often.

Fluids

IV fluid is used in traumatic shock to resuscitate when the radial pulse cannot be felt.
If there are delays in evacuating the casualty to definitive care maintenance fluids may be needed (depends on whether oral fluids can be given).
The route chosen to give these will depend on the casualty's condition and upon the resources available. A good guide to the adequacy of fluid replacement is the urine output: this should be at least 0.5ml/kg/hour (more if the casualty has/may have crush injuries or compartment syndrome).

Infection

A lower threshold for the use of antibiotics exists in a remote setting.
They are not, however, a substitute for good hygiene measures such as hand cleansing. Prevention is better than cure.
Wound management guideline if delayed or prolonged transport

Tubes

All tubes (including IV lines) must be regularly inspected to ensure they are working and to check for infection.
It is important to ensure they are adequately secured to the casualty, especially if the casualty is to be moved.

When using tape to secure a tube (e.g. IV fluid giving set), it is helpful to stick the tape to itself between the tube and the patient's skin to form a "mesentery". This allows a little side to side movement to occur without loosening the tube.
tape.jpg
When tubes are tied in place (e.g. chest drain, ET tube) a Prussik knot is useful as it is secure under tension but if the tension is removed the tube can be repositioned.
PRUSSIK.jpg
To secure IV lines in wet weather/on very clammy casualties cling film is effective. (Clingfilm is sometimes carried as first aid dressing for burns)
S2400003.JPG


Analgesia

There is a lot more to pain relief than the use of drugs (though they often have a very important role).
The carer's voice can make a big difference as can the correct use of splints.

Non-pharmacological

o Voice
o Dressings
o Distraction
o Splints

Oral analgesia

o Simple (paracetamol)
o NSAIDs
o Opiates
- Codeine
- Oramorph

Parenteral opiates

IV
Standard parenteral route
Allows titration
Rapid onset of action
Requires vascular access
IM
Cannot titrate so easily
No need for vascular access
Slower onset of action
In underperfused may be ineffective (and risk of excessive dose when perfusion restored)
Intra nasal
Difficult calculations and drawing up in children
Does not need vascular access
Requires diamorphine rather than morphine (more soluble)
Need for antagonist
Naloxone should be available if parenteral opiate is to be used
Transmucosal fentanyl
Is being used by the military

Nitrous oxide:oxygen

(sometimes called entonox though that is strictly speaking the apparatus to deliver the gas mixture)
Problems in cold (gases separate and need to be mixed)
Avoid if any gas “in the wrong place”: pneumothorax, intestinal obstruction, penetrating eye injury etc.
Very limited use in wilderness medicine because of the size and weight of the gas cylinders.

Nerve blocks

Lignocaine has short duration of action: bupivicaine may be preferable

Ketamine

Less respiratory depression than opiates (but not necessarily none at all)
Less cardiovascular depression than opiates
Can cause salivation / vomiting / emergence reactions
IV bolus ketamine is usually dosed initially at 0.2mg/kg – 0.4mg/kg for analgesia and 1 mg/kg for profound dissociation.; the literature reports a 0.25-11 mg/kg range.
Onset of action, which appears with glazed eyes and nystagmus, usually occurs within 1 minute.
Surgical anesthesia lasts about 15 minutes, with full recovery in about 60 minutes.
More dilute 10-50 mg/mL ketamine solutions are preferred for IV administration.
Perform the injection slowly to avoid ketamine-induced apnea (rare).

Records

It is much easier to maintain records as you go rather than try to write them up at the end. The standard to aim for is that if you were suddenly removed and replaced by another caregiver they would be able to take over casualty care from the written records alone.
Records need to include problems/injuries, treatments/interventions (inc drug dosages and timings), and observations.
Illegible records are not useful.

Sanitation

Plan ahead for this.
Remember you may need to monitor (and record) the volume of urine output

Environment

You need to protect the casualty from the environment - often cold is the biggest problem and remember that cold increases mortality from shock.


wiki_aframe.jpg
Using an A frame to help keep casualty warm



Reducing hypothermia after injury

Alaskan delayed care guidelines external image msword.png Delayed_Care_Guidelines.doc
NOLS guidance on medical decision making