impaled object- wrist

[Sacamuelas]

Originally posted by swatsurgeon
here's a (?) common scenerio........especially around explosions.
I'm going to attach a few pictures of impaled objects

3) nail in the wrist; common with suicide bombers wearing the palestinian dinner jacket (c4 with nails, rivits, washers, ballbearings, etc.)

How do you field manage......be specific..

T-2

Please work thread here. Thanks again Swatsurgeon

[Sacamuelas]

Originally posted by shadowflyer
I am in EMT-Intermediate school right now.

3. Airway, open and clear. Breathing, rate, rhythm and quality. Circulation, R,R,Q skin characteristics, CRT. Control any major bleeding. Rapid head to toe trauma assessment and fix injuries as you find them. Get a set of baseline vitals. 15l/m 02 NRB and 2 18g IV NS if in shock and titrate to mentation. Transport to bright lights and cold steel.

Jason

[Sacamuelas]

What about pain management? Options?

[shadowflyer]

Originally posted by Sacamuelas
What about pain management? Options?

MS 2-4 mg slow IV push with 12.5mg Phenegran IV push for nausea. Only if the BP was high enough, if he is shocky he wont be getting any pain meds.

Fentanyl lollipop would be an alternative with a responsive PT with patent airway.

Thoughts?

To add to my TX above that Doc Saca posted for me, I would splint affected hand/forearm to reduce movement that would further aggravate injury.

[Sacamuelas]

Those would work well. What if this soldier has to help fight his way out to evac? How about Ab treatment for this wound?

I would sure like to hear our new Surgeon's regional anesthesia ideas. SS or Doc T, would this be a good case for regional anesthesia to prevent the need for IV pain control?

[swatsurgeon]

back from vacation and ready to talk......
for that type of injury to the wrist, first see how much pain there is while in the 'neutral' position, apply splint, likely do a local block if needed. As long as the patient is neuro/vascularly intact, can continue to operate a weapon and protect themselves and evac when appropriate.
issues:
- splint, as well as one can in neutral position
-leave the impailed object alone......may be tamponading the radial artery and you would have a hell of a time explaining the touniquet on this one and..... YOU RUIN A PHOTO OPPPORTUNITY!!
- if it will be more than 4 hrs to evac and care, needs antibiotics.

Note: medic should have a supply of meds, po and IV/IM that covers the usual bugs for the usual injuries and alternate meds for allergies.

Down and dirty field test, flex and extend all digits, check for increased pain with movement and limit it based on that. Local block if needed but lidocaine will only last 30-60 minutes, 60-90 min. with epinephrine, 4-5 hrs if you use marcaine.

[ccrn]

Ditto...

Only I think Id go ahead and give him the abx anyway as you never know where you'll be in four hours especially if fighting your way out is a likelyhood.

What I'd be interested to know is if in an extremely remote OA, especialy if evac is unlikely for some time what then?

ccrn

[rogerabn]

Hmm.. well after he has evaluated for ABC’s and further injury, splint in neutral position, vascular and neuro checks, maybe MS4 2-15mg’s titrated, a gram of Ancef IV, evac to a tertiary facility and hope there is good ortho and possibly vascular surgeon available. The direction of the object makes me wonder about some neuro involvement. What to do if you can’t evacuate in a timely (like a month or two) manner. Pull it out and control the bleeding. Antibiotics and pain meds and hope for the best.

[ccrn]

Originally posted by rogerabn
...and control the bleeding...

Yes sir, but with a simple compression applique, or more ie is vascular repair within the scope of practice of 18D or "established surgical principles" as described in 18D skill set?

My searches for specific surgical skills result in "care of advanced trauma pt" which can be widely intrpreted-

ccrn

[NousDefionsDoc]

No, Deltas don't do vascular repair. I would start the AB therapy on the first listening halt. No sense in waiting.

Great thread.

[swatsurgeon]

I agree with the quick Abx...never know how long it will take.
Great question on the what if you won't/can't evac for several days.......
1) Find a nice safe, quiet place that you can spend at least an hour
2) Dig into your personal anatomy book in your brain and look at the trajectory of the object. Do an Allens test...hold pressure on both the radial and ulnar arteries and close the fist tight to push all blood out the veins, remember you are occluding the arterial inflow. Let go of the ulnar first and watch the hand...if the whole hand pinks up than don't worry about the radial, you have good collateral flow around the hand and it can survive on only one inflow. Remove the nail, hold alot of pressure for 5 minutes on the site....don't crush everything, just firm enough to stop arterial flow. Slowly peal your finger/thumb holding pressure back off. If it bleeds, keep holding for 10 minutes. If it stopped or never bled, it missed the artery?? You do have to remove it to decrease chances of infection. Likely will develop tendonitis or osteomyelitis, keep on Abx, after 6-8 hours of no bleeding, can begin ibuprofen or the like,maintain neutral position and get aid when possible. Worst case scerio, direct pressure until it clots or place a tourniquet on over a folded (into a tightly comressed wad) 4x4 gause sponge to direct the pressure right over the arterial injury and the tourniquet holds it firmly with out compromising the entire hand.....been there, done that.

[ccrn]

Ditto that too.

I do Allens at the bedside all the time to assess for art line placement. Although the surgeons do it themselves they like us to have a hand picked out already.

Only when we pull it out I hold pressure one inch above the site if arterial ten minutes no peeking, maybe five for venous.

Then I instruct the pt to not pull or place weight on the affected hand for at least two hours if they are able to follow commands or are compliant. If not I'll leave the wrist brace in place.

I was imagining a scenario where air assets might be very limited for a time or extraction would compromise a mission.

I was also thinking in terms of indigs. We have to be able to take care of them also and I wouldnt count on evac for them all of the time. Not that I wouldnt want to of course, just not sure if higher would allow for it-

ccrn

[rogerabn]

Thinking in terms of indigs:
1.Antibiotics and analgesia.
2.Brachial Plexus block
3.bp cuff above the elbow, pumped up as high as it can go (200mmHG preferably 250mmHg)
4.Start the clock, tourniquet time should be no more than 2 hours.
5.Prep the area
6.Remove the object
7.Flush the site with sterile saline
8.Explore for major vessel damage. Tie off any large vessels.
9.Deflate cuff, watch for bleeders, re inflate and flush with saline and tie off any new bleeders.
10.Repeat if necessary.
11.Dirty wound , so pack with wet to dry dressing don’t close
12.Splint and dry dressings on top
13.Be prepared for sepsis and the possibility of below elbow amputation
14.NSAID and antibiotics.
15.Dressing BID

[ccrn]

Originally posted by rogerabn
...Be prepared for sepsis...

In the event of SIRS or sepsis in an austere environment that might mean mostly fliud challenges and abx tx(empiricly or otherwise).

I wouldnt think pressors would be far fetched but quantity would sure be an issue as well as no pumps although they certainly could be supplied to a small field hospital or clinic set up and run by SF along with indigs-

[docbuxton]

hello everyone,
I'm a navy corpsman and a tactical medic on the civilian side. If you want to keep this guy in the fight I would do the standard pill pack of 1000mg. of tylenol, NSAID & an antibiotic. Then a nerve block with 2% lidocain. Does this sound good.

docbuxton