Wilderness and Rescue Medicine 7th Edition Jeffrey Isaac, PA-C and David E. Johnson, MD

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Section IV: Trauma

high-risk procedure, open the patient to infection, and become a significant wound management challenge. Open Fracture In an open fracture, the site is exposed to the outside environment through a wound in the skin. This opening can be produced from inside by sharp bone ends, or from outside by the same object that caused the fracture (such as a bullet). Unfortunately, this adds serious infection to the anticipated problem list.

Compartment Syndrome Swelling due to bleeding or edema inside a muscle compartment can increase intra-compartment pressure to the point that perfusion is impaired. The mechanism is usually blunt trauma or collat- eral damage from a fracture. It is also possible to see compartment syndrome develop from repeti- tive motion injury. Ischemia develops, with necro- sis of muscle and nerve tissue as the anticipated problem. Typical symptoms include severe pain out of proportion to the apparent injury, distal numbness, and pain on passive stretching of the affected muscle group.

An open fracture is a high risk problem that can be hidden by layers of clothing. Aggressive debridement (removal of foreign material and dead tissue) and irrigation with clean water are necessary before bone ends are pulled under the skin. The early use of prophylactic anti- biotics should be considered as part of the ideal

This fasciotomy was performed to relieve pressure and restore perfusion to muscle tissue affected by compartment syndrome. This is not a field pro- cedure. It is shown here to better illustrate the problem. With the right training and equipment, it is pos- sible to measure intracompartmental pressures and this is sometimes performed in the hospi- tal. However, it is more often the same signs and symptoms seen in the field that motivates a trip to the operating room; pain out of proportion, pain on passive motion, and distal numbness. The compartment is decompressed (fasciotomy) to relieve the pressure and allow blood to flow into the injured muscle. Compartment syndrome can develop hours to days after the initial injury. Field treatment includes anti-inflammatory medication, rest, elevation, and cooling of the extremity. Urgent evacuation is indicated if immediate improve- ment is not noted. A field fasciotomy would be a

General Principles

Open Fracture Wilderness Perspective

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• A’ is ischemia, bleeding, infection, and systemic infection.

• Free skin entrapments.

• Aggressive irrigation and debridement.

• Immediate treatment with antibiotics.

• Evac for surgical debridement.

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Low Risk High Risk

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field treatment. In cases such as crush injuries where bones remain exposed, moist dressings