EABLING LEARNING OBJECTIVES:
B. PHYSICAL EXAMINATION
Your powers of observation become crucial.
- Look for:
1. Swelling.
2. Discoloration and bruising.
3. Obvious deformity/angulation.
4. Open wounds. (with or without protruding bone fragments) 5. Differences right vs. left.
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6. Muscle spasm surrounding injured site.
7. Point tenderness.
8. Crepitus.
- Beware:
Consider the environment while assessing your patient - Don't undress the casualty in the cold!
- Protect your patient from the elements. (Sun, Rain, Cold)
- Talor your physical exam to meet the constraints of the environment.
* palpate under clothing.
* visualize one region at a time, then re-dress.
* set up temporary shelter from the elements.
3. Head Injuries:
a. A blow to the head may lead to increased intracranial pressure (ICP) or intracranial bleeding neither of which are managable in the wilderness. The job of the clinician is to diferentiate a serious life threatening injury from a minor one.
1. Minor injury: No loss of consiousness (LOC), or LOC of less than 15 seconds with immediate return to full alertness. The casualty can not be on
medications which increase risk of bleeding or have a history of bleeding disorders. Patient may be monitored every two hours for mental status changes, lethargy, irritibility, persistent nausea and vomiting, changes in speech or visual changes.
2. Serious Injury: LOC greater than 15 seconds, and/or persisitent confusion or memory loss; signs or symptoms of increased ICP: Debilitating headache, mental status changes, persistent nausea and vomiting, appearance of clear fluid in external auditory canal, Battle sign, raccoon eyes, or seizures.
3. Field treatment of serious head injury: Suspect injury of C-spine, manage airway-be able to clear vomit, elevate head 30 degrees. Evacuate to treatment facility ASAP.
4. Spinal Injuries.
A. Cervical Spine
1. High Risk Activities:
C-spine injuries in the wilderness usually occur after either a fall from a significant height or high-velocity accident from skiing. Common winter activities predisposing participants to C-spine injuries are skiing, snow-boarding, and snow-mobiling.
2. Anatomy:
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The cervical spine consists of seven cervical vertebrae interposed between the base of the skull and the thoracic spine. The cervical spine has a great deal of mobility to allow maximal range of motion for the skull. This increased mobility comes at a high price; this portion of the spine is less stable than the rest of the vertebral column, and hence more subject to injury. The C-Spine is stabilized by three longitudinal ligaments: The anterior longitudinal ligament (ALL) runs longitudinally along the anterior surface of the vertebral bodies. It is broad and very strong and helps to prevent hyper-extension of the head and neck. The posterior longitudinal ligament (PLL) also runs longitudinally, this time along the posterior surface of the vertebral bodies, within the vertebral canal itself. This ligament is relatively narrow and somewhat weaker than the ALL, and helps to prevent hyper-flexion at the neck. Third is the supraspinous ligament, connecting the spinous processes. This, too, is a strong ligament, acting to inhibit hyper-flexion.
The peripheral nerves innervating the muscles and the sensory nerves of the upper
extremities originate from the cervical portion of the spinal cord and these are some of the nerves likely to be affected in the event of a C-Spine injury. Hence, it is important to assess the
neurologic status of the upper extremities if a cervical injury is suspected.
3. C-Spine Injury Statistics:
-Most common injury: Flexion injury at C5/6 (so look for a deficit in the C6 distribution) -28% of C-Spine injuries have another spinal fracture associated with it.
(so examine entire spine)
-10% of Head injuries/Facial fractures also have a C-Spine injury, especially if there was LOC.
4. Remember:
a. Head injury -> Assume C-Spine injury.
b. Perform complete Neurovascular exam
-Motor, Sensory, Reflexes, Pulses, Babinski reflex.
B. Clear a C-Spine. (FMST.07.14a)
When faced with a possible C-Spine injury in the Wilderness, clearing it without X-ray should be considered only in extreme situations. However, there are situations which demand that every effort be made to make a casualty ambulatory, because the movement of the individual would demand herculean effort from the rest of the team, potentially placing more individuals at risk of injury or prolonging exposure to extreme environmental conditions.
Clearing a C-Spine in the field should follow a three-phased assessment. If the patient fails the assessment at any one of the phases, then the team is obligated to maintain spinal
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precautions and transport the patient. The phases are outlined below, and expanded upon in the lecture.
PHASE ONE:
-ensure no alteration of mental status.
-maintain in-line traction.
-perform complete neurovascular exam (focusing on the upper extremities) -palpate spinous processes one-by-one while asking
casualty whether palpation causes pain (supraspinous ligament) -distinguish between pain over spinous process and
muscle soreness associated with paraspinal musculature.
-only if palpation was completely pain-free can you move on to ...
PHASE TWO:
-continue to maintain in-line traction
-palpate anteriorly to the left and right of trachea.
along the anterior vertebral bodies (anterior longitudinal ligament).
-Assess for bony tenderness under the angle of the jaw to the clavicle.
-Distinguish between tenderness of the
sternocleidomastoid muscle and actual vertebral pain.
-only if palpation was pain-free can you progress to...
PHASE THREE:
-while loosely maintaining in-line traction, have patient move head through active range of motion
*first flexion/extension
*followed by rotational movement
-stop test at the first indication of pain with movement
Note: If you are able to move the patient's head through a full range of motion without pain, you have effectively cleared his C-Spine. Have the patient resume activity slowly and cautiously;
evaluate any other complaints noted.
B. Thoracic and Lumbar Spine:
-Look for a T-L Spine injury with calcaneal fractures. Approximtely 10%
of patients with a calcaneal fracture will also have an associated lumbar fracture.
C. Pelvis:
-Think HEMORRHAGE/SHOCK if faced with a Pelvic Fracture
*Up to 6 liters of blood loss possible – (internal iliac areteries)*
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Place gentle constricting wrap around pelvis if open book fracture is suspected. (FMST.07.14b)
4. FRACTURES.
Some common wilderness fractures:
a. Metacarpal/Phalangeal -the hands are your means of interfacing with the environment, sometimes it's a forceful meeting.
b. Distal Radius -Very common wilderness fracture.
c. Scaphoid -check for snuffbox tenderness, pain with axial load to thumb.
d. Lunate -also common, pain dorsally at base of 3rd MC.
f. Clavicle -need good NV exam, check for pneumothorax.
g. Long bone -Radius/Ulna: if proximal, check elbow
-Humerus: radial nerve runs in spiral groove -Tib/Fib: think compartment syndrome- Fib fx
may ambulate with cane
-Femur: think Hemorrhage, think traction.
f. Ankle -commonly a fracture/dislocation, check NV g. Hip - Leg will typically be externally rotated REMEMBER: - Always think HEMORRHAGE with Long Bone fractures
- Always perform NEUROVASCULAR Exam before and after treatment - Always SPLINT AND PAD for stability, comfort, function and transport.
- Indications for REDUCTION are: NV deficit , severe angulation, severe pain, if angulation prediposes to open fx or makes transport difficult.
- OPEN FRACTURES: Have 6-8 hours to get to surgery. Field Gently wash off with betadine/ iodine solution to get off obvious don’t scrub. Wrap in sterile gauze. Don’t place exposed bone back under skin. Give antibiotics: Augmentin, 2nd or 3rd generation cephalosporin, a quinolone or tetracycline.
THE REASONS WE PLACE FEMUR FRACTURES UNDER TRACTION.
1. Re-establishing length tightens fascia and tamponades bleeding.
2. Dramatic pain relief.
3. Helps prevent open fractures.
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4. Helps reduce secondary soft tissue damage.
5. Increases ease and safety of transport.
SOME BASIC RULES OF EXTREMITY SPLINTING:
- Splint all fractures before moving the casualty, unless in imminent danger.
- Splint all fractures as they are found, unless severe angulation complicates transport or is causing neurovascular deficits.
- Splint to include the joint above and below.
- Construct splints using uninjured extremity, then splint in the position of function, comfort or stability.
5. DISLOCATIONS.
a. Rapid Diagnosis and Reduction is imperative, if evacuation time is > 1-2 hours.
- Easier to reduce immediately after injury. (muscle spasm) - Makes transport much easier. (increased patient comfort) - Dramatic pain relief.
- Early reduction reduces risk of Neurovascular injury.
- Reduction could make difference between an ambulatory vs. litter patient
*the safety of the entire expedition could be placed at risk*
b. Signs and Symptoms: Remember, NO X-RAYS!
- Decreased Range of Motion.
- Obvious Deformity. (compare right vs. left) - Usually NO Crepitus.
- Typical Posture.
c. Reduction Techniques:
- Phalanges Linear traction, buddy tape. Can not reduce volar displacement of 1st phalanyx.
- Shoulder Bedsheet method- counter traction.
Prone with weights method.
External rotation.
Snowbird technique.
- Patella Extension with medially directed pressure.
- Ankle Linear traction with knee flexion.
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- Hip Anchor pelvis, hip flexed at 30 degrees, upward traction.
- Sternoclavicular Roll between scapulae, and apply forceful downward pressure.
-Knee Should only be reduced as an absolute last resort. Apply anterior traction gently.
REMEMBER: Analgesia and Sedation should be utilized when available before attempting joint or fracture reduction, unless multiple traumatic injuries are present.
6. EVACUATION CRITERIA:
Conditions demanding expeditious evacuation: (FMST.07.14c) 1. Suspected cervical, thoracic, and/or lumbar spine injuries.
2. Pelvic injury with instability and/or significant blood loss.
3. Any open fractures. (6-8 hour window, antibiotics early)
4. Compartment syndromes. ( pain with passive motion, pallor, pulseless, paresthesia)
5. Hip or Knee dislocations.
6. Any other injury the medical provider feels he/she is not prepared to manage.
7. OTHER TRAUMA.
Heavy bleeding: Usually can be treated by direct pressure, if a tourniquet is required,release pressure every five minutes to reassess.
Contusion: Apply ice 1st 48 hours which will provide pain relief and limit expansion of hematoma.
Lacerations and avulsions: High pressure irrigation with clean water, may remove debris with flame treated forceps. Use steri-strips for minor clean lacs. Keep dirty or puncture wounds open and give antibiotics.
Animal Bites: Copious irrigation, and antibiotic, do not close. Consider rabies if bite was unprovoked and animal was acting strange. (bats, raccoons, skunks, canines, and felines) Has never been seen in livestock, rabbits, squirrels, rats or mice.
Most common zoonotic source in North America is the skunk.
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Severed part: Can be reattached up to 24 hours after injury if the cut is clean. Gently clean part, wrap in gauze and keep cool without freezing.
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UNITED STATES MARINE CORPS Mountain Warfare Training Center
Bridgeport, California 93517-5001
FMST.07.38 04/02/02 STUDENT HANDOUT
REPTILE AND ARTHROPOD ENVENOMATION BITES AND STINGS