Wilderness and Rescue Medicine 8th Edition

81

Section IV: Trauma

deformed fractures and pain. It is important to remember that musculoskeletal injuries and lac- erations are never, by themselves, life-threatening problems. The severe bleeding associated with a femur or pelvis fracture is a circulatory system problem. Difficulty breathing in the presence of a rib frac- ture is a respiratory system problem. Altered men- tal status with a skull fracture represents a nervous system problem. Your primary assessment and basic life support (BLS) should recognize and treat the critical system problems without being distracted by broken bones, pain, and superficial wounds. Trauma patients do not die of fractures, sprains, strains, and contusions. They die from shock, respiratory failure, and brain injury. The Golden Hour The emergency medical services (EMS) subscribe to the golden hour in trauma management as the ideal time within which the patient should access surgical care and stabilization. This is rarely pos- sible in wilderness and offshore situations but speed can still save lives. It is time to move fast if your scene size-up or primary assessment reveals existing or anticipated critical system problems. Multiple-trauma patients need a hospital. In some situations, the secondary assessment will have to wait, perhaps even until the patient is out of the Experience in combat medicine from the begin- ning of the 20th century through the Vietnam War demonstrated that aggressive fluid resuscita- tion of trauma patients in the field can often be deadly rather than helpful. The intent in giving intravenous (IV) fluid to patients in shock is to maintain perfusion pressure and cellular oxygen- ation. Unfortunately, higher pressure within the circulatory system can also disrupt clot formation, dilute clotting factors , and exacerbate bleeding. During more recent conflicts in the Persian Gulf, American medics have been instructed to withhold IV fluid from bleeding casualties who were still producing enough perfusion pressure to operating room. Hold the Fluid

maintain A on the AVPU scale. If fluid is deemed necessary it is titrated to maintain peripheral pulses, not necessarily to restore normal blood pressure. Volume is not fully restored until opera- tive control of bleeding is established in the hospi- tal. Fatalities frommajor battlefield injuries have fallen to 12% from a century-long constant of 22%.

Use caution in trauma; rapid IV fluid adminis- tration can exacerbate uncontrolled bleeding and contribute to hypothermia. The implications for wilderness rescue are clear: for the trauma patient in shock from internal bleed- ing IV fluid replacement is less of a priority than finding a surgeon and a hospital. If fluid replace- ment is performed, care should be exercised to avoid diluting blood and clotting factors with IV solutions. Maintaining body core temperature to preserve clotting function, ensuring oxygenation, and evacuating rapidly are more likely to save a life than reading blood pressure and starting an IV.