Question Time

Discussions of the best (or worst) equipment to have on hand for use in the event of an injury during an emergency.

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Arsenul
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Question Time

Post by Arsenul » Fri Jun 28, 2013 1:37 am

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I want to be able to treat something like this if ever I need to. What do you suggest I do to get started?
Tell me I can't do it and watch as I prove you wrong.

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Re: Question Time

Post by Shiloh » Fri Jun 28, 2013 1:52 am

Excuse the language, but fucking ow.

Ummm...sutures? Lots of 'em.
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Re: Question Time

Post by Arsenul » Fri Jun 28, 2013 1:55 am

Shiloh wrote:Excuse the language, but fucking ow.

Ummm...sutures? Lots of 'em.
I'd assume there would be more to do.
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Re: Question Time

Post by Shiloh » Fri Jun 28, 2013 1:58 am

Arsenul wrote:
Shiloh wrote:Excuse the language, but fucking ow.

Ummm...sutures? Lots of 'em.
I'd assume there would be more to do.
Yeah, I figured as much. I'm no EMT, so unfortunately I can't think of much.
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Re: Question Time

Post by Arsenul » Fri Jun 28, 2013 2:02 am

Shiloh wrote:
Arsenul wrote:
Shiloh wrote:Excuse the language, but fucking ow.

Ummm...sutures? Lots of 'em.
I'd assume there would be more to do.
Yeah, I figured as much. I'm no EMT, so unfortunately I can't think of much.
OK thanks.
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Re: Question Time

Post by RugbyFire » Fri Jun 28, 2013 6:07 am

It would be interesting to see how someone would approach this if they didn't have the training or knowledge, yet had to do something to help the victim.
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Re: Question Time

Post by maldon007 » Fri Jun 28, 2013 6:15 am

untrained me- clean as good as I could with the cleanest water I had & if it was a dirty environment, add the best/safest disinfectant I could find. Pack with gauze if I have it (if not, whatever is close to gauze, that I can get, that is clean) & tape it up to stop bleeding, then get him to someone who can inspect for muscle/tendon damage, suture it up and prescribe meds/antibiotics (yeah, the hospital :lol: )

If there is no hope of getting him to a pro, I might attempt some type of closure... Either duct tape use like butterflies... or suture the best I can (makes me cringe a bit)... or whatever other way I can come up with.
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Re: Question Time

Post by kbilly84 » Fri Jun 28, 2013 6:32 am

First thing you should do, is edit the thread title to warn those who get queasy at pics like that.

For the actual wound (I'm no EMT/MD/PA/RN/etc), I see two major avenues of treatment, based on whether or not it's likely that the individual can get to a better care facility to be treated by a pro.

If yes, call 911, etc. Attempt to stop (or at least control) the bleeding (QuikColt/Celox), wrap with Kerlix, prepare for transit. Watch out for shock, etc. Basically keep the individual conscious and responsive until the pros can take over.

If no, stop the bleeding and clean/debride the wound. I'd be hesitant to use sutures in a situation like that, due to the risk of infection. That's my primary concern if I'm long-term without professional help. Perhaps rigging up a way to hold it together to allow healing, but that allows me to examine for infection?

Questions for the pros around here: Is there an antiseptic recommended for something like that? If suturing is required, what steps should be taken to prevent infection?

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Re: Question Time

Post by CrossCut » Fri Jun 28, 2013 6:47 am

No medical training here, but will throw this out and hope to learn from the pro's responses. Have the supplies to pull it off, including inj. lidocaine, assuming I was at home and not out in the field.

The lacerations appear clean and with sharp edges, and recent. No serious hemorraging, so that's good. Thoroughly irrigate with clean water/saline under moderate pressure, and if it's been under 6 hours or so from when the injury occurred then I'd consider suturing if it's a clean wound, as from a knife as it appears. That vertical slash looks pretty deep at the midpoint, that's going to require subdermal suturing with catgut first I'd bet, then another set to close the skin - else suture the less deep sections and pack wet-to-dry on the deeper ones. Start Keflex or Augmentin prophylactically.

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Re: Question Time

Post by Stercutus » Fri Jun 28, 2013 7:56 am

Go to medical school and become a doctor.

That guy is going to need surgery for proper treatment. Assuming it is not photo shopped some of those cuts are well into the muscle. Without a doctor I guess you could stitch him up, treat for infections and immobilize him for a month. His back will never be the same.
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Re: Question Time

Post by shrapnel » Fri Jun 28, 2013 8:23 am

Why that specifically? Are you beset by machete-wielding maniacs (or bears. Machete-wielding bears)?

Also, please put a gore warning in the thread title.
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Re: Question Time

Post by medic photog » Fri Jun 28, 2013 6:20 pm

Trained here. Those lacs are deep, but not that deep and nothing looks to be spurting or bubbling. Flush, dress, go. In a remote area, some third world countries, or a PAW, you could consider packing and steri strips maybe. There doesn't seem to be that much bleeding and they really look like they are only superficial. Judging by the fact his head is already bandaged, there was possible something else here that needed attention first.

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Re: Question Time

Post by CrossCut » Fri Jun 28, 2013 9:44 pm

medic photog wrote:Trained here. Those lacs are deep, but not that deep and nothing looks to be spurting or bubbling. Flush, dress, go. In a remote area, some third world countries, or a PAW, you could consider packing and steri strips maybe. There doesn't seem to be that much bleeding and they really look like they are only superficial. Judging by the fact his head is already bandaged, there was possible something else here that needed attention first.
Think that shiny stuff on his upper left shoulder is his scapula, and enlarging the pic I can count his ribs (or the meat still clung to then anyway). There's also a lot of broken blood vessels on his center back right side, blunt force trauma (?) of some type I didn't notice before. His head and the bandage on his right abdomen looks like it's already been treated. Wonder if they stopped the blood vessels from bleeding on the lacs on his back with electro-cauterization (or whatever it's called)? That look like some pretty deep wounds not to be bleeding at all now that I think about it.

Great post here I think, would love for the pros here to quiz the noobs with "patient presents" stuff like this. For those cases where "and evac them asap" isn't an option. Thanks.

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Re: Question Time

Post by DrJack » Sun Jun 30, 2013 12:51 am

If this happened outside a bar or club, treat what you can of bleeding, early EMS transport.

If this is in the PAW, pack wounds to allow to close from inside out. Scars will be terrible. ABX with whatever you have. Ertapenem/Invanz is a favorite for battle wounds around here.

If you're not trained in suturing you'll just muck it up, so don't bother. Chances of this guy going septic and dying are high, but is definitely survivable given decent shelter and some common sense nursing.
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Re: Question Time

Post by Veritas » Wed Jul 03, 2013 12:18 am

Of course PAW is different than real life, so I'll pretend this is PAW:

Approach all traumatic wounds the same.

First, stop bleeding with pressure. Once the bleeding stops, look in the wound. This will cause it to bleed more, which is okay. Wash the wound out with as much clean (not sterile) water as you can. Make sure you look how deep it is. Make sure the person can move everything distal (that means farther out) to the injury. If they can't, that gives you a clue that the wound is deeper than just the top layers of skin. In any case, you're in the PAW, you will do the same thing anyway.

I would not pack a wound in the PAW. Packing doesn't seem to be well supported, and only chronic wounds really need to heal by second intention. If this is fresh, you can see the bottom, and you can clean it, I see no reason to not close it. It would need to be closed in layers, and you would need absorbable sutures for anything below the skin. Close the top with absorbable or nonabsorbable, doesn't really matter.

I also would not routinely give this wound antibiotics. Info from the Afghan and Iraqi wars has really made medics and other first responders quick to give antibiotics, but honestly it's a different scenario than most practice in, and it is certainly different scenario than the PAW. If you have no back up hospital, save the antibiotics, wash out well, don't pack and close if you can explore it. Not to be nit-picky, but Ertapenam is a little broad for this, maybe for penetrating abdominal wounds, but the worst bug you would worry about here is MRSA, so anything with good Gram positive coverage should suffice, I don't think you need to empirically cover for Gram negatives as well.

If you can't fully explore the wound, don't close it, watch for infection, and keep it as dry as possible. Clean it out when it looks nasty. If it gets really bad, well, that's another post. Packing may be good in that case.

If they have a loss of function, I would still do all the above but then splint whatever extremity is having the problem.
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Re: Question Time

Post by abelru » Wed Jul 03, 2013 1:32 am

OR, all day long.

If primary closure is a realistic end-goal (scenario-wise) the only safe, effective, and efficient method is with 'hot lights and cold steel'.

Trying to locally anesthetize this guy would not only be frustrating, it would be potentially dangerous given the toxic amount of lidocaine one would conceivably need to administer. Plus, you would need a REALLY cool dude to sit through that mess conscious.

OR management would also allow for thorough inspection, irrigation and (if necessary) debridemont of any foreign matter or compromised/devitalized tissue. One area that concerns me on this guy is the skin island formed at the right most convergence of the two horizontal lacerations and the transecting vertical laceration. Probably well perfused, but if not, will become necrotic and problematic in a very short time.

Time-wise, staples beat sutures hands down. You could have him done in 1/5 the time with staples. Arguably better from a dehiscence standpoint as well.

Wound characteristics would indicate that this injury was inflicted by something potentially nasty. Claws, teeth, machete, agricultural equipment, etc. While I agree with what Veritas says in terms of not routinely treating lacerations with antibiotics, I would consider it for this guy and would also consider gram negative coverage as well depending upon mechanism.

And let's not overlook ensuring tetanus is up to date.

In austere conditions, nothing more than basic but really good wound care.
Initially, wet to dry dressings to promote granulation and hasten tissue coverage, converting to dry dressings as soon as possible.
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Re: Question Time

Post by CrossCut » Wed Jul 03, 2013 8:28 am

Thinking PAW only here. Modifying and elaborating a bit on my earlier thoughts based on suggestions here, and still assuming it's a clean wound:

1) Irrigate with copious amounts of clean water/saline, under pressure from a syringe as needed.

2) Apply powdered sulfa and pack the vertical lac at its deepest points with saline dampened sponges.

3) Use the 30-40ml or so (?) of 1% lidocaine (w/o epi, don't have any) that can be safely administered to suture the upper horiz. wound where the bone is exposed first, then anywhere else where the wound edges approximate well without leaving a cavity beneath until his lido for the day is gone, or the pt can't tolerate it further. Going to have to get a stapler for the reasons abelru mentioned.

4) Clean the unbroken skin around the wound edges with diluted Betadine and bandage everything.

5) Keflex (500mg qid) or Augmentin (875mg bid).

6) Change the dressings twice daily, irrigating and reapplying sulfa. If the packed ones show any signs of infection, add Flagyl (500mg, tid/qid) in addition to the Keflex/Augmentin.

7) If the deep/packed wounds aren't showing any signs of infection in 4-5 days, might consider closing them then, to speed healing and save gauze.

This guys most serious risk of death now is from infection, he'll live otherwise. Not to suggest I believe AB's are a replacement for proper wound cleaning and care, but I'd want to treat for infection pretty aggressively - not wait 3-4 days to find it's infected, then 3-4 more days to maybe find out I chose the wrong antibiotic (or that it's resistant). Have plenty of AB's, so treating this guy isn't going to leave me short. Not a Dr, and ready to be wrong though.

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Re: Question Time

Post by Veritas » Thu Jul 04, 2013 12:14 pm

Here's a question: If you're gonna use staples, why numb it? I've been giving patients the option, most take the lidocaine, some do not. I've had some that request the shot after initially refusing, then tell me the lidocaine hurt worse than the staples and to go back to no lido. Me personally, I've had it both ways, not sure which I prefer.

Or more interesting still, anyone used subQ benadryl, or simply subQ saline? I've read about it, never done it, then you would avoid a toxic lidocaine dose.

In reality he would just be sedated. Ketamine maybe? But that's definitely out of just about everybody's scope here...
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Re: Question Time

Post by Stercutus » Thu Jul 04, 2013 12:24 pm

I asked the wife who mentioned that if the bone was nicked well enough osteomyelitis has a good chance of killing the dude or making his life a living hell without getting proper wound treatment. Once it gets started there really is only one way to treat that.....
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Re: Question Time

Post by Veritas » Thu Jul 04, 2013 12:44 pm

Being truthful, if this is the PAW, it's probably a fatal wound. It's deep, extensive, and will severely limit mobility. Care will be supportive, and he may even have contractures from scars limiting his ROM if he heals.

In the modern world, very treatable, just flush it out, control bleeding until he is transported to a hospital. There they will give anesthesia, do fun surgery things, and he will have follow up in a clinic with lots of sweet percs at home.

In the mean time we will argue an inbetween world where we have limited resources but theoretically enough knowledge to do a combination of the above two things, and then argue more about which, of many, complications will ultimately kill him.
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Re: Question Time

Post by DannusMaximus » Thu Jul 04, 2013 3:52 pm

Step 1 is to determine if this guy is a dirtbag or not. After that determination, the matrix is as follows:

If he is a dirtbag and was injured by another dirtbag while they were doing dirtbaggy things (brawling over an Xbox game, carved up by a broken beer bottle because he popped off to some other idiot's not-cute-enough-to-fight-over girlfriend, pushed through a plate glass window because he wouldn't consummate a low-level drug deal quickly enough), then no further treatment is needed. He will miraculously survive with little or no care with these wounds, and will promptly apply for (and receive) disability payments for the rest of his life due to the emotional trauma inflicted by the attack. He will die of old age after siring an even dozen kids that he doesn't even attempt to support. They will also grow up to be dirtbags.

If the wounds were more extensive, you would need to get any three pieces of him to an ER. It is important to note that these three pieces don't even have to match, just get them to the nearest ER. There, after taxpayers have spent $100s of thousands of dollars on surgery and rehabilitation, he can apply for (and receive) disability payments for the rest of his life due to the emotional trauma inflicted by the attack. He will die of old age after siring an even dozen kids that he doesn't even attempt to support. They will also grow up to be dirtbags.

If the person is NOT a dirtbag, the matrix is as follows:

He's probably going to die no matter what you do, but only after extensive treatment that exhausts his private insurance and bankrupts his family with medical bills. On the off-chance that he does not die, he will be unable to work but will be turned down for disability because he tries to follow the rules and doesn't have any dirtbag buddies who can point him to an attorney or physician who can help him game the system in his favor.

Yes, yes I have made a slew of medical runs recently that left me feeling a bit cynical about the state of health care in this country... :?
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Re: Question Time

Post by DrJack » Thu Jul 04, 2013 9:49 pm

I think DannusMaximus has it.

Veritas is on point with our presumptions and arguing.

I prefer staples to sutures most of the time, (Getting and giving) and prefer staples without local. (Getting and giving)

I carry vials of benadryl that I can use subQ and Doc is cool with us using it for local, but have never done it.

I carry enough Ketamine to put this guy under but wouldn't want to without another good medic or 3 to help run shit for me.

If you have sterile water, you should have normal saline too, use that not water to wash out.
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Re: Question Time

Post by tac57 » Fri Jul 05, 2013 1:26 am

What you would do depends on the distance from medical aid. First, lets assume a hospital is still an option, but care will be delayed by hours to days. This is standard wilderness medicine stuff. If this is true, then:

1. First, do a full assessment of the patient and manage any immediate life threats. Although this is urgent, we need to know if there is anything more life threatening present. Check and reassess your ABCDE's. Manage c-spine. Place pt on Oxygen, cardiac monitor and Spo2 if available. Obtain vascular access if indicated, and run on a saline lock or TKVO infusion. This is standard ATLS and prehospital care.

2. CONTROL bleeding. Bleeding will cause hypovolemic shock if not corrected, and this shock WILL kill your PT if it is profound enough. You must control the bleeding as best as possible. Use direct pressure and hemostatic agents if required (do not use these unless direct pressure fails and the bleeding is major arterial or venous - oozing is OK). In this case bleeding appears controlled.

3. Assuming all that has been taken care of, then examine the wound. Since a hospital IS still an option, it is better to let the surgeons take care of the final repair. In the wilderness med context, early wound care is critical, early closure is not. Closure of a wound creates a whole other set of challenges that are best left to the docs in the hospital if you can.

4. Assess the wound. Assess and explore the wound. How deep does it go? Is it a clean laceration or more complex (e.g tearing)? Explore wound edges. From this formulate a treatment plan. For this PT the wounds are deep and long. They appear to be clean, straight lacerations. Do a CSM check on the lower extremities to assess neuro status (possible neuro injury from lacs). We will assume this is normal.

5. IRRIGATE. Use several litres or more of sterile (if not sterile than the cleanest drinking water available). Use a 60 mL syringe with a 14-18 gauge angiocath on it. Flush out each laceration with copious amounts of saline. Good BLS wound care will work wonders to prevent ifxn in these PTS.

6. Dress. Since the hospital IS still an option, we will want to leave the wounds open for the hospital to definitively manage. Consider packing the wounds, mainly to control bleeding (this may not work, but it could be an option). Either leave open, or temporarily close with tape in several spots, forming a sort of "transpore steri-strip. The goal is to keep the wound relatively clean and control bleeding.

7. Reassess ABCDE's and treat as found. Prevent hypothermia at all costs (hypothermia, acidosis and coagulapathy are the lethal triad of trauma. Avoiding hypothermia keeps your PT alive)

8. Ongoing care and pain management. Arrange for evac, preferably by air ambulance. Pain could be controlled with IV or IM opiates, possibly fentanyl at a dose of 50-100 mcg. Have naloxone and airway management equipment on hand (BVM, supraglottic airways and if able to do so, ET intubation gear). Toradol MAY be an option, but be extremely cautious about the risk of bleeding.

Now lets assume that a hospital is NOT an option. This will require AGGRESSIVE care. If this is true, then:

1. First, do a full assessment of the patient and manage any immediate life threats. Although this is urgent, we need to know if there is anything more life threatening present. Check and reassess your ABCDE's. Manage c-spine. Place pt on Oxygen, cardiac monitor and Spo2 if available. Obtain vascular access if indicated, and run on a saline lock or TKVO infusion. This is standard ATLS and prehospital care.

2. CONTROL bleeding. Bleeding will cause hypovolemic shock if not corrected, and this shock WILL kill your PT if it is profound enough. You must control the bleeding as best as possible. Use direct pressure and hemostatic agents if required (do not use these unless direct pressure fails and the bleeding is major arterial or venous - oozing is OK). In this case bleeding appears controlled.

3. Assuming all that has been taken care of, then examine the wound. Since the hospital is NOT an option, the wound will need to be managed surgically. You DID have your suture kit in your medical bag, didn't you?

4. Assess the wound. Assess and explore the wound. How deep does it go? Is it a clean laceration or more complex (e.g tearing)? Explore wound edges. From this formulate a treatment plan. For this PT the wounds are deep and long. They appear to be clean, straight lacerations. Do a CSM check on the lower extremities to assess neuro status (possible neuro injury from lacs). We will assume this is normal.

5. Sedate. Local anesthesia is not a good option, simply because the amount of lidocaine (or other local anesthetic) required would rapidly reach the toxic dose (which for those of you who don't remember, is 300 mg or 4.5 mg/kg of lidocaine - whichever is less). The drug of choice for me (assuming austere environment where you could get access to anything) would likely be ketamine given by IV push. Give 1-2 mg/kg to start, then increase as needed to a max of ~4.5 mg/kg. What you want is deep sedation or general anesthesia. This will hurt like H**L. Unlike most sedative drugs, ketamine does not affect the respiratory drive of the PT and will actually slightly increase BP. It is an "all in one" drug with both dissociative and analgesic properties.

6. IRRIGATE. Use several litres or more of sterile (if not sterile than the cleanest drinking water available). Use a 60 mL syringe with a 14-18 gauge angiocath on it. Flush out each laceration with copious amounts of saline. Good BLS wound care will work wonders to prevent ifxn in these PTS.

7. Close the wound. The wound is deep, involving several tissue layers. Use absorbable subcuticular sutures to close the Sub-Q tissue. I'd likely use vicryl. For the surface of the wound, you can use absorbable or nonabsorbable sutures.Close the wounds per standard technique. Staples could also be an option for the skin once the sub-Q tissue is repaired w/ sutures.

8. Dress. Apply sterile dressings to the wound. Op-site or a similar dressing would work great, as they are water resistant yet allow visualization of the wound.

9. Reassess ABCDE's and treat as found. Manage PT during emergence from ketamine anesthesia. Emergence rxn if present can be treated with ~2 mg of midazolam.Prevent hypothermia at all costs (hypothermia, acidosis and coagulapathy are the lethal triad of trauma. Avoiding hypothermia keeps your PT alive)

10. ABx prophylaxis is probably not indicated based off of the literature. However, if signs of ifxn develop, then use of a broad spectrum abx may be warranted. Use your clinical judgement.

11. Ongoing care and pain management. Pain could be controlled with IV or IM opiates, possibly fentanyl at a dose of 50-100 mcg o morphine at a dose of 2-5 mg. Start low and go slow. Have naloxone and airway management equipment on hand (BVM, supraglottic airways and if able to do so, ET intubation gear). Toradol MAY be an option, but be extremely cautious about the risk of bleeding.

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Re: Question Time

Post by RugbyFire » Fri Jul 05, 2013 2:40 am

If you had to make a hasty band-aid, what would be the safest material to use.
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