Linda Laskowski Jones, MS, RN, ACNS-BC, CEN, FAWM · Linda Laskowski Jones, MS, RN, ACNS-BC, ......
Transcript of Linda Laskowski Jones, MS, RN, ACNS-BC, CEN, FAWM · Linda Laskowski Jones, MS, RN, ACNS-BC, ......
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Linda Laskowski Jones, MS, RN, ACNS-BC, CEN, FAWM
Explain wound care priorities in an austere or
wilderness environment.
Describe management considerations pertinent
to animal bites.
Develop strategies for wilderness emergency
preparedness.
Identify wound type
Achieve hemostasis
Evaluate extent of injury
Prevent infection
Consider treatment options
Consider the need for rapid evacuation
Principle: In the wilderness, you do the best that you can with what you have!
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Many causes of wounds in the wilderness!
Blisters
Abrasions
Lacerations
Puncture wounds
Amputations
Open fractures
Burns
Animal & insect bites
Firm, direct pressure
Layer dressings
Elevation / pressure
points
Hemostatic dressing
Tourniquet: for life-
threatening hemorrhage
Shock management
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Hemorrhage control
Shock management
Wrap body part in dry, sterile dressing material
Place wrapped part in plastic bag if available
Place bag with part in an ice slurry
Do not allow part to get wet or freeze
Transport body part with patient to hospital
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Fully expose injured area
Assess wound:
Location
Dimensions (width, length, depth)
Severity of contamination
Presence or absence of foreign body
Bone, tendon, joint & nerve involvement
Assess distal neurovascular & nerve function
Typical contaminants:
Skin flora: S. aureus (including methicillin-
resistant species)
Soil: Clostridium & Pseudomonas species
Oral flora from bites: Pasteurella, Eikenella &
Streptococcus
Irrigate wound: use cleanest water available;
use water purification devices / tablets
Remove visible foreign material / contaminants
Up-to-date on tetanus prophylaxis?
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Factors
Time elapsed since injury
Injury location
Extent of contamination
Injury severity & degree of
underlying tissue involvement
Injury mechanism / forces
Immune competence of patient
Leave wound open or close? Judgment call – based
on degree of contamination & potential for infection
High risk wounds: Leave open
Pack with saline or water-moistened gauze &
dress; change packing daily; oral antibiotics
Wound closure:
Anesthesia available? Probably not…but, if so:
LET: topical lidocaine, epinephrine & tetracaine;
massaged over wound for 20-30 min (associated
with slight increase in wound infection rate)
1% lidocaine for local infiltration (need supplies)
Ice
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Methods to re-approximate edges: wound edges should touch but not be tightly pulled together
Tape
Wound closure strip or micropore tape / benzoin
Duct tape with perforations made with a safety pin toward sticky side for wound drainage
Tie hair together using pieces of dental floss to knot & pull edges closed for scalp lacerations
Skin adhesives / glue (no topical antimicrobials if a cyanoacrylate product is used; will dissolve glue)
Staples – consider if available & wound will remain clean; never use on the face
Suture – not usually feasible unless in clinic setting
Commercial non-adherent pads and/or dressing
materials
Cleanest available improvised materials (e.g.,
bandana, T-shirt)
Wounds involving joints: consider splinting area to
decrease risk of wound re-opening
Topical antibiotics if no skin glue is applied:
bacitracin best; neomycin OK but more allergies
Honey also acts as a topical antimicrobial
Change dressings at least once daily
Indications for prophylaxis:
Complex or mutilating wounds
Gross wound contamination / penetrating debris
Extensive ear & cartilage lacerations
Animal bites
Bone, joint or tendon penetration
Immunosupressed patients or those with
valvular heart disease
Indications for treatment:
Wounds with signs of infection
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Prophylaxis: 3-5 day course
First generation cephalosporin
Amoxicillin-clavulanate Clindamycin
For suspicion of MRSA:
Trimethoprim/sulfamethoxazole Clindamycin
Doxycycline
Infection: 7-10 day course
Tailor to suspected organisms & local resistance patterns
Stop the burning process
Remove clothing & jewelry in area
1st degree: apply aloe vera gel
Large blisters: consider draining &
debriding
Apply antibiotic ointment
(Silvadene, bacitracin) or honey
Cover burn with dry, sterile dressing
Splint burned extremities in position
of function
Prevent hypothermia / Evacuate
Reverse triage / CPR for any
victim in cardiac arrest
Trauma management
Burn Injury:
Range from superficial to full thickness, linear
charring or contact burns from overlying metal
objects
Lichtenberg figures or keraunographic
markings appear as branching or ferning
marks on skin (erythematous arborization)
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DO NOT:
Apply lotions, salves, or greasy
substances
Apply ice to burns
Disrupt blisters if they are small
Native to all states except
Maine, Alaska & Hawaii
Bite ~ 4,700 people / year
Pit vipers are venomous at birth
Snake bite-related deaths:
2 to 5 deaths per year
More common in children & elderly
No antivenin, inadequate or late dose
Usually occur 18 - 32 hours after envenomation,
but may occur earlier
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Young, adult males > age 20
Children < 10 years of age
Persons under the influence of drugs or alcohol
Use of snakes in religious rituals or “sport”
Rattlesnakes, Cottonmouths & Copperheads
Heat sensitive pit between each eye & nostril;
enables snake to locate warm-blooded prey
Triangular head due to presence of venom
glands; venom immobilizes & digests prey
Two curved, canalized fangs--retract when mouth closed
3 pairs replacement fangs (fang replacement occurs throughout snake’s life)
Snake regulates venom quantity based on size of prey; can inject from one or both fangs
Amount of venom injected variable in defensive bites
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Recognition: Venomous or Harmless?
Applicable to North American Pit Vipers
Venomous
• Triangle-shaped
head
• Elliptical pupil
• Pit
• Fangs
• Rattle--rattlesnakes
Non-venomous
• Rounded head
• Round pupil
• No pit
• No fangs /
small teeth
No Envenomation (“Dry” Bite)
Fang marks without local or
systemic reaction
Minimal Envenomation
Fang marks, local swelling, pain
Rubbery, minty or metallic
taste in mouth
No significant systemic effects
Moderate Envenomation
Fang marks with local & systemic effects: pain,
nausea, vomiting, paresthesias, fasciculations,
swelling beyond bite site, mild coagulopathy
Severe Envenomation
Fang marks with severe swelling / local
response, severe systemic manifestations,
including hypotension & seizures
Marked coagulopathy
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Severe Envenomation
Emergency Interventions in the Field:
Move victim to safe area away from snake
Advise rest (exertion speeds venom effect)
Remove jewelry & tight clothing
Splint & immobilize bite area at heart level
Evacuate to hospital ASAP
Emergency Intervention
DO NOT!
Apply ice
Apply a tourniquet
Incise or suck wound
Capture / handle snake
Note: even DEAD or
decapitated snakes can
inflict a bite -- take a digital
photo instead!
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Poison Control Center
Prophylactic fasciotomy not recommended;
swelling from myonecrosis typically resolves with
adequate antivenom administration
Radiographic imaging to identify embedded teeth
or fangs in bite wound
Consider antivenom (CroFab): Enhanced safety
profile: no skin testing; administer within 6 hours if
possible
Tetanus prophylaxis / wound care; antibiotic
prophylaxis not routinely indicated
Don’t molest snakes – use common sense!
Don’t keep venomous snakes as pets
Stay out of striking distance
Use caution in snake-infested areas: rocks, tall
grass, caves & heavy underbrush
Don’t put hands & feet where eyes can’t see
Wear boots & protective clothing
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Severity varies: depends upon animal &
reason for attack; most do not attack unless
provoked Most attacks occur far from definitive care Initial wound care similar to domestic animal
bites Blunt trauma / crush injury common Antibiotic coverage is same as for domestic
animals Wounds are tetanus-prone & generally left
open Consider need for rabies prophylaxis
Top speeds up to 40 mph
Attacks more common in
summer
Brown Bears: higher rate
of attack than black
bears
Sudden close encounter
Mother with cubs
Most dangerous: bears
that view humans as prey
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Make noise; be cautious
Avoid common bear areas
Pepper spray may be useful:
Must be used within 30 feet right into
bear’s face
Do not use on skin or clothes
Should not be sprayed in camp as a deterrent
Consider carrying a marine / road flare
Never feed a bear
Keep campsite free of garbage
Store food in approved containers & out of reach (hung at least 10ft up in tree or on pole)
Never keep food / scented items in your tent
Remember the 100m triangle: Assure 100m between the campsite, the food storage & cooking areas
Never approach a mother bear with her cub
Do not look directly into the bear’s eyes
Do not run or make sudden movements
Do not act aggressively
Stand your ground; back up slowly
Backpack may offer some
protection
If attacked, get into fetal position,
cover head & play dead
Bears can climb trees
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If an attack is immanent:
Yell & throw things
Look big
Act aggressively toward
bear; black bears tend to
retreat
If attacked: kick & fight
aggressively as that bear
has no fear of humans &
may want to eat you!
Becoming more common
Frequently stalk, pounce &
break the cervical spine
May be scared off by
aggressive behavior
Look big; cluster with hiking
partners
Keep backpack on for protection
Fight back with any object
available
Do NOT run away
Scene safety: Mountain lion
may still be in area
Manage ABC’s: control
massive hemorrhage
Remove debris & foreign
objects, including teeth
Assess for fractures
Evacuate for definitive care
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Rabies
•All mammals can be infected,
esp. bats, raccoons, skunks, foxes
•Transmission:
• Scratch or bite from infected animal; saliva
contact with open wounds, eyes, nose or
mouth, inhalation of aerosolized virus
•Animal may exhibit behavior change!
•20 to 60 day incubation, but may be 9 days to > 1
year for human rabies
•Common cause of human death in developing
countries
• Treatment: No effective treatment for symptomatic disease; nearly always fatal!
• If animal isn’t available, victim must start post-exposure prophylaxis Post-exposure Prophylaxis:
#1 – Immediate wound cleansing – soap & water!
#2 - Human Rabies Immune Globulin—RIG: injected into bite site & IM for passive immunity
#3 - Rabies vaccine 1 ml Deltoid IM for active immunity (Days 0, 3, 7, 14 --new CDC 4-dose regime) --Immunosuppressed patients: 5th dose day 28
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Medium size, light brown with fiddle-shaped mark
on back (“fiddleback” or violin spider)
Live in dark, secluded areas
Venom has cytotoxic effects on tissue; bites
cause ulcerative lesions
Bite may be painless, stinging to sharp & painful
Intense aching & pruritus in minutes to hours
Central bite site: bleb or vesicle surrounded by
expanding erythema; later becomes dark &
necrotic with eschar
Systemic effects rare, but occur
Differential diagnosis: MRSA
Interventions:
Apply cold compress intermittently for first
4 days after bite
Do NOT apply heat--will increase enzyme
activity of venom & worsen wound!
Rest & elevate affected area
Supportive care: topical antiseptic & sterile
dressing; antibiotics if infected
May need debridement & skin grafting
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Don’t place hands & feet where
eyes can’t see
Inspect clothing & shoes
Inspect bedding
Wear protective clothing &
gloves when in areas
that harbor spiders
Tentacles have
barbed, venom-
charged nematocysts
that fire stinging cells
Toxins injected into
skin & enter victim’s
circulation
Reaction to toxin may
cause collapse in
water & drowning
Mild Reaction:
Rash with stinging, itching, tingling, burning & intense throbbing pain
Red-brown-purple tentacle prints or welts Skin infection can occur
Moderate to Severe Reaction: Multiple, body-wide effects including muscle
spasms, nausea, vomiting diarrhea, stomach pain, severe pain at sting site
Anaphylaxis
Organ failure, coma & death
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Prevent firing of nematocysts:
Wash area with sea water (not freshwater)
Hot water or topical lidocaine best for pain Do not rub or compress
Avoid vinegar: widely advocated but increases pain after stings of most jellyfish species
Remove tentacles with tweezers or gloved hand Shave area with shaving cream or baking soda
paste to remove nematocysts
Pain control (ibuprofen, acetaminophen), diphenhydramine, tetanus immunization
Etiology: Skin exposure to below-freezing
temperatures with ice crystal formation
Increased risk: Inadequate or wet clothing,
fatigue, poor nutrition, smoking, alcohol & drug
use, impaired circulation
Occurs most in extremities, with higher incidence
in feet than hands
First Degree
Pale, white & numb while frozen
Edema & hyperemia after rewarming
Area is pale, white & numb while frozen
After rewarming, redness, edema & clear to white fluid-filled blisters
Second Degree
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Complete tissue freezing; pale, white & numb
Pain, redness & edema with rewarming
Blisters contain dark, hemorrhagic fluid; surrounding skin is red or blue & may not blanch
Involves skin, muscles, tendons & bone
Area is pale, white & numb while frozen
“Chunk of wood” consistency
Mottled skin with bluish discoloration forms deep, dry, black-crusted lesion; gangrene develops
Splint to minimize motion, pad between fingers
/ toes & elevate
Before thawing, give ibuprofen 400 mg q 12h
(inhibits inflammatory cascade)
Re-warm rapidly in 40 C water bath (104 –
108F hot tub temp)
Note: Slow rewarming increases thromboxane
& prostaglandin production; causes secondary
damage
Pain control!
Tetanus prophylaxis
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DO NOT: Use dry heat Thaw if part can refreeze Rub or massage area when frozen Rub frostbitten area with snow
Note: If evacuation delay is expected,
do not rewarm! Better to have victim walk out on frostbitten foot.
Synthetic base layer (Cotton kills!)
Wool / down / synthetic insulating layers
Waterproof / wind-proof outer layers
Hat / face protection (balaclava)
Gloves (mittens are warmer) & glove liners
Wool / synthetic socks (1 pair)
Sun glasses or goggles
Adequate nutrition
Adequate fluid intake
Avoidance of alcohol
Tetanus prophylaxis up-to-date
Consider medical supplies based upon type of
austere / wilderness environment / excursion, trip
duration, risks & personal skills / training
Medications: broad-spectrum antibiotics
Communications: emergency contacts & travel
insurance
Rabies prophylaxis?
Know when to evacuate
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AdventureMed.
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from a non-venomous snake? Wilderness Medicine,
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