Wilderness and Rescue Medicine 8th Edition

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Section IV: Trauma

A tetanus vaccine booster should be given to anyone with an open wound who has not had a vaccination within ten years, or within five years in cases of high-risk wounds. This is ide- ally done within 24 hours of injury but does not warrant an evacuation if the person has already been immunized at some point. You can keep this from becoming a problem by keeping your rou- tine tetanus vaccinations up to date and ensuring that everyone else in your group does the same. Monitor the wound for signs of infection wheth- er you choose to evacuate or not. You should also monitor the circulation, sensation, and movement (CSM) distal to the injury as you would with a musculoskeletal problem. Bandages, splints, and swelling can create ischemia there as well. Evisceration Internal organs protruding from an abdominal or chest wound is a gruesome scenario, but pos- sible with penetrating trauma to the abdomen or thorax . Eviscerated organs should be covered with wet gauze or occlusive dressings like plastic wrap, and the patient evacuated to surgical care as rapidly as possible. Allowing a bent-knee posi- tion in the litter will reduce the tension of the abdominal wall and help prevent ischemia of the extruded organs.

into the body cavity. Systemic infection, shock, and death are inevitable without surgical care. Hypothermia is an anticipated problem during evacuation. Traumatic Amputation Full or incomplete amputations should be treated with the expectation that replantation is possible, or at least that tissue and skin from the ampu- tated part can be useful in repair of the stump. Successful replantation has been accomplished after as much as 24 hours. The surgeon should decide which injuries are candidates for replanta- tion; your job is to get your patient and the ampu- tated part to the appropriate facility as soon as possible. The ideal field treatment is to wrap the ampu- tated part in a gauze sponge soaked with saline, place it in a plastic bag, and float the bag in ice water. Bleeding from the patient’s amputation site should be controlled only with direct pressure, and the wound maintained with moist dressings. Tourniquets and clamps should be used only if bleeding cannot be controlled otherwise. In the absence of ice and sterile saline to pre- serve the amputated part, a dressing moistened in clean water or 1% PI solution will suffice. Keep the part as cool as possible without freezing and continue with the evacuation. Partially amputated extremities are treated the same way while still attached to the patient. Do not cut the part free. Treatment of Traumatic Amputation If managed correctly, an amputated extremity is not a life-threatening injury. Despite the drama and urgency of the situation, do not risk the lives of the patient and rescuers to preserve the pos- sibility of replantation. A live patient with an arti- ficial limb confirms a successful rescue. A fatality during the evacuation does not.

General Principles

Abdominal Evisceration

• Do not push the organs back inside. • Apply moist or occlusive dressings. • Position with knees bent. • Emergency evacuation, anticipate: - Shock - Hypothermia - Systemic infection - Organ ischemia 20

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Positioning the patient for transport may result in spontaneous reduction of the evisceration , or you may attempt gentle manipulation that allows the organs to slide back inside. No attempt should be made in the field to push the organs back