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Scott Kujath, MD, FACSClinical Associate Professor, University of Missouri—Kansas CityClinical Associate Professor, Kansas UniversityClinical Associate Professor, Kansas City University

Aboutme:� Medical Credentials

� Midwest Aortic and Vascular Institute, founding partner� Board Certified Vascular Surgeon� Board Certified Undersea and Hyperbaric Medicine� Board Certified General Surgeon

� Service� Living Room Ministries International, Board Treasurer� Mission of Hope Clinic, Board Chair� MetroCare, Board of Directors� Kansas City Medical Society, Board of Directors

Aboutme:� Mission Trips:

� Jamaica—Won by One to Jamaica� Mauritania—Mercy and Truth Medical Missions� Kenya—Living Room Ministries International� Turkey—Tom Cox World Ministries� Raytown, Missouri—Mission of Hope Clinic

� Husband, father of three teens

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Disclaimer

�I avoid trauma while traveling whenever possible!

Definitions:� Trauma: injury; physical injuries of sudden onset

requiring medical attention, possibly requiring immediate resuscitation.� Lacerations, fractures, burns, head injury, solid organ

injury, multi-system injury (MVC, etc.)� The leading cause of mortality worldwide

� Trauma Management: helping the patient who has a traumatic injury. Starts with “First Aid”

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Definitions:� First Aid: help given to injured until full medical

treatment is available

� Limited Resource Setting: typically in developing countries, but also certain situations in developed countries when expert help and supplies are not immediately available.

KnowtheLocalResources� What resources does the team have?� What transportation is available?� Where is the nearest hospital or clinic?� How is care paid for?

Jacob� A teacher’s apartment invaded by armed thieves� Shot through torso and left to die� Neighbors placed him in a taxi to the hospital� He sat in the Emergency Room until morning before

anyone attended to him� 1 year later admitted to inpatient hospice with multiple pressure ulcers secondary to paraplegia, ready to die.

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KnowtheLocalResources� What resources does the team have?� What transportation is available?� Where is the nearest hospital or clinic?� How is care paid for?

TypesofTrauma� Open Wounds� Fractures� Burns� Head injury� Shock

FirstAid� Basic medical aid� Basic Life Support (BLS), CPR� Psychological support

� Remain calm!

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PrimarySurvey� Airway assessment and protection� Breathing and ventilation� Circulation/hemorrhage� Disability, basic neuro exam� Exposure, with environmental control

VitalBodyFunctions� Breathing process� Respiration� Airway� Lungs� Rib cage

� Blood circulation� Heartbeat� Pulse

� Carotid� Femoral� Radial� Posterior tibial

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Adverseconditions� Lack of oxygen� Bleeding� Shock� Infection

Evaluationofinjured� Send for help� Check for responsiveness

� “Are you OK?”� Check for breathing

� Clear airway and ventilate

� Check for pulse� CPR?

� Check for bleeding� Evaluate for wounds� Treat as required

� Immobilize fractures

Evaluationofinjured� Check for shock

� Clammy� Pale� Restless or nervous� Thirst� Bleeding

� Confusion� Fast breathing� Blotchy or bluish skin� Nausea or vomiting

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Checkforfractures� Back or neck injury

� Pain� Cuts� Bruises� Paralysis� Numbness

� Immobilize neck/back

� Open� Bleeding� Bone protruding� Check pulse

� Closed� Swelling� Discoloration� Deformity� Check for pulse

Check forburns� Reddened� Blistered� Charred� Singed clothing

Checkforheadinjury� Unequal pupils� Fluid from ears, nose,

mouth or wound� Slurred speech� Confusion� Sleepiness� Loss of memory or

consciousness

� Staggering� Headache� Dizziness� Nausea or vomiting� Paralysis� Convulsions or twitching� Bruising around eyes or

ears

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AirwayandBreathing� Check for responsiveness� Call for help� Position on back, if unconscious and injuries allow

� “log roll” if necessary� Open airway

� Head-tilt/chin-lift� Clear debris—finger sweep� Jaw-thrust

AirwayandBreathing

Breathing� Look, chest rise and fall� Listen, air escaping from mouth and nose� Feel, for air flow� Perform, rescue breathing if required

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AirwayandBreathing

ObstructedAirway� Abdominal thrusts� Chest thrusts

ProtectWound� Expose wound� Do not tear clothing from wound� Evaluate for multiple wounds� Apply dressing

� Cleanest material available� Sterile� Clean� Clothing

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StopBleeding� Manual pressure

� 5-10 minutes� Injured may hold pressure

� Elevate limb above heart� After splinting, if required

� Pressure dressing� On top of initial dressing

� Digital pressure (pressure points)� Femoral, popliteal� Axillary, brachial� Carotid, temporal

� Tourniquet� Last resort� Severed limb

Improvisedtourniquets� Pad the skin under the tourniquet� Gauze, clothing, canvas

� Do NOT use wire or shoestring� Stick � Do not release once placed� Keep tourniquet visible

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Shock� Cardiovascular collapse

� Cardiogenic� Cardiac injury

� Hemorrhagic/hypovolemic� Traumatic injury� Dehydration

� Vasodilation� Allergic reaction� Sight of blood� Neurologic injury

Shock� Clammy� Pale� Restless or nervous� Thirst� Bleeding

� Confusion� Fast breathing� Blotchy or bluish skin� Nausea or vomiting

Shock—FirstAid� Position

� Under cover� Lay on back

� Reposition only as injuries allow

� If breathing difficulty, sitting up may be better tolerated

� IV fluids, if available� Avoid food or drink

� Elevate feet� Loosen clothing� Prevent chilling or

overheating� Maintain calm� Seek medical aid

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HeadInjuries� Scalp injuries

� Abrasions and lacerations� Depressed skull fractures� Assume spinal injury

HeadInjuries� Unequal pupils� Fluid from ears, nose,

mouth or wound� Slurred speech� Confusion� Sleepiness� Loss of memory or

consciousness� Blurred vision

� Staggering� Headache� Dizziness� Nausea or vomiting� Paralysis� Convulsions or twitching� Bruising around eyes or

ears� Deformity of the head

Neckinjuries� Apply pressure above and below� Do not compress airway� Evaluate for cervical spine injury

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Facialinjuries� Soft tissue injury is common� Bleeding can be severe� Evaluate for underlying boney injury

Head,Neck, FaceFirstAid� Clear airway� Control bleeding� Treat shock� Maintain temperature� Protect wound� Do not force tissue back into skull� Do not apply pressure dressing� Concussion

Eyeinjuries� Lacerated/torn eyelids

� Cover with sterile dressing� Do NOT use pressure

� Lacerated eyeball/extruded eyeball� Cover with loose sterile dressing� NO pressure� Bandage both eyes

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Eyeburns� Chemical

� Flush with copious amounts of water� Acid

� Flush for 5-10 minutes� Alkali

� Flush at least 20 minutes

� Bandage eyes

EyeBurns� Thermal

� Do NOT apply a dressing� Do NOT touch

� Light burns� Loosely bandage eyes to protect from bright lights

Convulsions� Ease to ground� Support head and neck� Maintain airway� Protect from further injury� Do NOT forcefully hold limbs� Do NOT force anything between teeth

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ChestWounds� Expose wound

� Remove clothing� Don’t remove from within wound

� Evaluate for “sucking” wound� Pneumothorax

� 3 sided occlusive dressing� Remove and replace for

respiratory distress

� Position on injured side

From Combat Medic Advanced Skills Training

From Combat Medic Advanced Skills Training 44

NeedleChestDecompression

Abdominalwounds� Position on back with knees up

� Relieves abdominal pain� Relieves pressure� Treats shock� Prevents further exposure of bowel

� Expose wound� Gently place organs on abdomen with cleanest avaialable

material; do NOT force back in body� Dress with cleanest material avilable

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Burn Injuries� Thermal� Electrical� Chemical� Laser (eye injury)

ThermalBurn� Eliminate source of burn� Stop, drop and roll� Cold water for 20 minutes if available� Cover with clean non-synthetic material

� Synthetics may melt into wounds

Electrical Burn� Turn off electrical current� Remove patient from electrical source using non-

conductive material� Wood� Cloth� Dry rope

� Body-to-body contact may cause injury to rescuer� Entrance and exit wounds� Deep injury is likely with high voltage

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ChemicalBurn� Use water to flush away liquid chemicals� Brush away dry chemicals� Flush away chemicals with copious amounts of water� If large amounts of water are not available, then use

NO water

LaserBurn� Remove from source� Never look directly at source

BurnDressings� Use the cleanest dressing material available� Do NOT cover face or genitals� Do NOT break blisters� Do NOT apply grease or ointments

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Fractures� Closed

� No break in skin� Open

� Bone may protrude� Penetrating injury may break skin

Signs andSymptomsofFractures� Deformity� Tenderness� Swelling� Pain� Inability to move injured part� Protruding bone� Bleeding� Discolored skin at injury site� Sharp pain with attempts to move injured site

ImmobilizeFractures� Keep bone from moving

� Protect tissue, muscle, nerves, blood vessels� Reduce pain� Decrease of creating an open wound

© 2014 Doom and Bloom (TM)

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ImmobilizeFractures� Splints� Bandages� Slings� Swathes

Splints� Immobilize the joint above and below the fracture� Use sticks secured with cloth strips� Boots should not be removed unless there is a foot

injury to evaluate� Pad the boney prominences� Check circulation distal to injury� Remove any jewelry� Dress open wounds� Do NOT attempt reduction of fracture

SlingandSwathe

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Spinalcolumnfractures� Immobilize� Log roll

HeatInjury� Heat cramps

� Muscle Cramps� Drink water

� Heat exhaustion� Signs and symptoms

� Excessive sweating with pale, cool skin

� Headache� Weakness� Dizziness� Chills� Tingling� Confusion

� Drink water� Pour water on and fan patient� Rest for rest of day

� Heat Stroke� Stops sweating� May pass out� Medical emergency� Drink water if conscious� Active cooling� Massage extremities to

increase circulation� Elevate legs

ColdInjury� Signs and Symptoms

� Numbness or tingling� Discoloration of skin� Reddened, paleness or

grayness to skin� Swelling and blisters

with rewarming

� Treatment� Gradually rewarm� Use body heat� Avoid

� Massaging� Fire or stove� Soaking in cold water� Rubbing with snow

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Hypothermia� Prevent any further heat loss� Rewarm� Warm liquids may be helpful if conscious

SnakeBites� Identify the snake� Remain calm and still� Do NOT elevate the limb� Place a band proximal to the bite� Remove jewelry� Seek medical attention� Tetanus update

Humanbites� Cleanse with soap and water� Cover with sterile dressing� Seek medical attention

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AnimalBites� Capture or kill animal for testing� Cleanse with soap and water� Cover with sterile dressing� Immobilize extremity

Insect bites/stings� Remove stinger� Remove jewelry� Ice or cold compress� Meat tenderizer or calamine lotion� Constricting bands for more serious reactions� Identify insect� Anaphylaxis—Epi pen

Resource

� First Aid, Field Manual No.4-25.11, 23 December 2002

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AirwaySupport� Spinal immobilization� Jaw thrust� Neck immobilization

Hemorrhagecontrol� Direct pressure� Pressure points� Tourniquet

OpenWounds� Stop bleeding

� Direct pressure� Pressure points/digital pressure� Tourniquet

� Expose wound to evaluate extent of injury� Wash wound

� Saline� Water

� Dress wound with sterile/clean dressing

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Fractures� Obvious deformity� Bones through skin� Unusual body position� Deformity � Discoloration� Swelling� Check for pulse

Burns� 6 million people seek medical attention annually

worldwide� Children ~50%� Mechanism of injury

� Thermal (scald, flame, contact)—95%� Electrical, chemical—5%

Burns� Zone of coagulation/necrosis

� No tissue perfusion� Irreversible damage

� Zone of stasis� Decreased perfusion� Chance of tissue recovery

� Zone of hyperemia� Good perfusion� Likely tissue recovery http://generalsurgery-fkui.blogspot.com/2011/06/luka-bakar.html?m=1

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Burns� Systemic response

� Greater than 20-30% TBSA� Extensive inflammatory mediator release� Hypotension� Bronchoconstriction� Increased basal metabolic rate� Reduced immune response

Burns� Initial management, within 3 hours

� Limit damage and mortality� Check that the scene is safe� Stop the burning process� Remove the patient to safe place� Remove non-adherent clothing� Cool the wound (not the patient)

� Cool water irrigation� Within 20 minutes� For up to 30 minutes

� NOT ice

Burns� Cover the burn

� Prevent infection and desiccation� Relieve pain� Plastic wrap for thermal burns

� Not circumferential� Cotton sheets for chemical burns and if plastic not

available� Avoid overly saturated dressings

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Burns� Estimating size of burn

� Palmer surface of hand is ~1% body surface area� Rule of nines

� Refer if� >10-15%� Circumferential� <10 y/o� >50 y/o

https://myhealth.alberta.ca/Health/_layouts/15/healthwise/media/medical/hw/h5551003.jpg

HeadInjury� Quality of speech� Confusion � Unequal pupils� Sleepiness� Staggering

� Dizziness� Paralysis� Nausea or vomiting� Bruising around eyes

or ears

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Resources� First Aid, Field Manual No.4-25.11, 23 December 2002� International Best Practice Guidelines: Effective Skin and

Wound Management of Non-Complex Burns, Wounds International, 2014 www.woundsinternational.com

� Mock C, Lormand JD, Goosen J, Joshipura M, Peden M. Guidelines for essential trauma care. Geneva, World Health Organization, 2004

Questions?