prolonged+field+care

=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 ||
 * 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.

<span style="font-family: Verdana,Geneva,sans-serif;">Fluids
<span style="color: #ff0300; font-family: Georgia,serif;">**IV fluid is used in traumatic shock //to resuscitate// when the radial pulse cannot be felt.** <span style="font-family: Georgia,serif;">If there are delays in evacuating the casualty to definitive care //maintenance fluids// may be needed (depends on whether oral fluids can be given). <span style="font-family: Georgia,serif;">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).

<span style="font-family: Verdana,Geneva,sans-serif;">Infection
<span style="font-family: Georgia,serif;">A lower threshold for the use of antibiotics exists in a remote setting. <span style="font-family: Georgia,serif;">They are not, however, a substitute for good hygiene measures such as hand cleansing. Prevention //is// better than cure. <span style="font-family: Georgia,serif;">[|Wound management guideline if delayed or prolonged transport]

<span style="font-family: Verdana,Geneva,sans-serif;">Tubes
<span style="font-family: Georgia,serif;">All tubes (including IV lines) must be regularly inspected to ensure they are working and to check for infection. <span style="font-family: Georgia,serif;">It is important to ensure they are adequately secured to the casualty, especially if the casualty is to be moved.


 * <span style="font-family: Verdana,Geneva,sans-serif;">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. || [[image:wildernessmedicine/tape.jpg]] ||
 * <span style="font-family: Verdana,Geneva,sans-serif;">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. || [[image:wildernessmedicine/PRUSSIK.jpg width="325" height="291"]] ||
 * <span style="font-family: Verdana,Geneva,sans-serif;">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) || [[image:wildernessmedicine/S2400003.JPG width="320" height="239"]] ||

<span style="font-family: Verdana,Geneva,sans-serif;">Analgesia
<span style="font-family: Georgia,serif;">There is a lot more to pain relief than the use of drugs (though they often have a very important role). <span style="font-family: Georgia,serif;">The carer's voice can make a big difference as can the correct use of splints.

<span style="font-family: Verdana,Geneva,sans-serif;">//Non-pharmacological//
<span style="font-family: Georgia,serif;">o Voice <span style="font-family: Georgia,serif;">o Dressings <span style="font-family: Georgia,serif;">o Distraction <span style="font-family: Georgia,serif;">o Splints

<span style="font-family: Verdana,Geneva,sans-serif;">//Oral analgesia//
<span style="font-family: Georgia,serif;">o Simple (paracetamol) <span style="font-family: Georgia,serif;">o NSAIDs <span style="font-family: Georgia,serif;">o Opiates <span style="font-family: Georgia,serif;">- Codeine <span style="font-family: Georgia,serif;">- Oramorph

<span style="font-family: Verdana,Geneva,sans-serif;">**IV**
<span style="font-family: Georgia,serif;">Standard parenteral route <span style="font-family: Georgia,serif;">Allows titration <span style="font-family: Georgia,serif;">Rapid onset of action <span style="font-family: Georgia,serif;">Requires vascular access

<span style="font-family: Verdana,Geneva,sans-serif;">**IM**
<span style="font-family: Georgia,serif;">Cannot titrate so easily <span style="font-family: Georgia,serif;">No need for vascular access <span style="font-family: Georgia,serif;">Slower onset of action <span style="font-family: Georgia,serif;">In underperfused may b e ineffective (and risk of excessive dose when perfusion restored)

<span style="font-family: Verdana,Geneva,sans-serif;">**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

<span style="font-family: Verdana,Geneva,sans-serif;">**Transmucosal fentanyl**
Is being used by the military

//<span style="font-family: Verdana,Geneva,sans-serif;">Nitrous oxide:oxygen //
<span style="font-family: Georgia,serif;">(sometimes called entonox though that is strictly speaking the apparatus to deliver the gas mixture) <span style="font-family: Georgia,serif;">Problems in cold (gases separate and need to be mixed) <span style="font-family: Georgia,serif;">Avoid if any gas “in the wrong place”: pneumothorax, intestinal obstruction, penetrating eye injury etc. <span style="font-family: Georgia,serif;">Very limited use in wilderness medicine because of the size and weight of the gas cylinders.

<span style="font-family: Verdana,Geneva,sans-serif;">//Nerve blocks//
<span style="font-family: Georgia,serif;">Lignocaine has short duration of action: bupivicaine may be preferable

<span style="font-family: Verdana,Geneva,sans-serif;">//Ketamine//
<span style="font-family: Georgia,serif;">Less respiratory depression than opiates (but not necessarily none at all) <span style="font-family: Georgia,serif;">Less cardiovascular depression than opiates <span style="font-family: Georgia,serif;">Can cause salivation / vomiting / emergence reactions <span style="font-family: Georgia,serif;">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. <span style="font-family: Georgia,serif;">Onset of action, which appears with glazed eyes and nystagmus, usually occurs within 1 minute. <span style="font-family: Georgia,serif;">Surgical anesthesia lasts about 15 minutes, with full recovery in about 60 minutes. <span style="font-family: Georgia,serif;">More dilute 10-50 mg/mL ketamine solutions are preferred for IV administration. <span style="font-family: Georgia,serif;">Perform the injection slowly to avoid ketamine-induced apnea (rare).

<span style="font-family: Verdana,Geneva,sans-serif;">Records
<span style="font-family: Georgia,serif;">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. <span style="font-family: Georgia,serif;">Records need to include problems/injuries, treatments/interventions (inc drug dosages and timings), and observations. <span style="color: #ff0000; font-family: Georgia,serif;">Illegible records are not useful.

<span style="font-family: Verdana,Geneva,sans-serif;">Sanitation
<span style="font-family: Georgia,serif;">Plan ahead for this. <span style="font-family: Georgia,serif;">Remember you may need to monitor (and record) the volume of urine output

<span style="font-family: Verdana,Geneva,sans-serif;">Environment
<span style="font-family: Georgia,serif;">You need to protect the casualty from the environment - often cold is the biggest problem and remember that cold increases mortality from shock.



<span style="font-family: Georgia,serif;">[|Reducing hypothermia after injury]

<span style="font-family: Georgia,serif;">Alaskan delayed care guidelines [| Delayed_Care_Guidelines.doc] <span style="font-family: Georgia,serif;">NOLS guidance on medical decision making