ATLS in The Austere Environment Flashcards
Learning Objectives
- Define austere and hostile environments.
- Explain treatment priorities in the context of environment and relative risk.
- Identify available resources and options.
- Adapt resources to meet the goals of ATLS.
Define ‘Austere environment’
Austere/remote environment: environments where access to clean water, electricity, and to a fixed or mobile medical facility is significantly degraded or denied, and where diagnostic and treatment resources and medical personnel are unavailable or limited for extended periods of time.
State one Austere environment
- Military: Limited resources
- Wilderness: Extremes of the environment (Hella cold or hot)
Describe the military aspects of Austere environment
- Massive wounds from explosions
- Haemorrhage control
- Back to basics – ABCs and debridement
- Seek additional training
List some hostile environments
- Disasters including:
- Natural
- Manmade: War, Industrial, Terrorism
List some considerations when travelling to Austere or hostile environments
- Personnel
- Equipment and supplies
- Communication
- Transportation
What does hospital based patient care typically entail?
- Involves personnel: abundant consultants
- Sophisticated resources and technology
- Availability of supplies
- Shelter
- Evacuation and transport
How do you prepare & plan on travelling to an Austere environment?
- Travel to an Austere Environment
- Stay fit and healthy
- Plan: Water, food, clothing, shelter, Communication
- Be invited as part of a team
- Personal effects in order
How do you prepare & plan on travelling to an Hostile environment? (PART 2)
- Hostile Environment
- Regional plan with fire, rescue, police, civil, military, and hospital personnel
- Threat assessment
- Equipment and supplies
- Emergency sources for power, water, and supplies
How do you prepare & plan on travelling to an Hostile environment? (PART 2)
- Hospital Environment
- Detection and treatment of toxic agents
- Protective clothing
- Respiratory protection
- Regular drills and practices
What are the treatment options for Airways?
- Standard approach: Look, listen, feel
- Available resources: Suture through tongue
- Definitive airway: Tactile / digital intubation
- Surgical options
What are the treatment options for breathing?
- Ventilators may not be available
- O2 may not be available: Prioritise
- Bag-mask device or definitive airway for up to 24 hours
- Important: Judicious use of all resources
What are the treatment device options?
- Cricothyroidotomy: Ink pen or other small tube
- ET tubes as chest tubes (easier to pack)
- Open wounds: Use what’s available (eg, plastic wrap)
- Underwater seal drainage: Heimlich valve, surgical gloves with finger cut
What are the Treatment Options for Circulation?
- Supplies may be used up quickly
- “Walking” blood bank
- Oral hydration
- Application of pressure, limb elevation
- Properly applied tourniquets
- Careful BP restoration if no OR
List some special circumstances to consider in different environments
- Pain management
- Management of specific injuries
- Preparation for transport
- Environmental extremes
- Communication
- Triage
How do we treat “Pain management”?
- Immobilization
- Avoid intramuscular narcotics
- Consider: Oral agents, IV / IM ketamine, Local anesthetics
How do we treat “Specific injury management” for the abdomen?
- No CT or FAST
- No tests if no OR
- DPL for triage
How do we treat “Specific injury management” for the musculoskeletal system?
- Improvised splints
- Sheet to close pelvis
- Elevate extremity
How do we treat “Specific injury management” for burn injuries?
- Mortality high with optimal resources
- Severe burns with other injuries may put patient in expectant category
- Other factors: Inhalation injury requiring intubation, Fluids for resuscitation
How do we prepare for patient transport?
- Do no further harm
- Find shelter (high ground)
- Move patient as little as possible
- Keep warm and dry
- Anticipate delay in evacuation
How do we manage environmental extremes?
- Plan: Clothing, food, fluids, shelter, and activity level
- Cold: Prevent heat loss
- Heat: Correct fluid and electrolyte abnormalities (oral / parenteral)
How do we manage communications in these environments?
- Preplanning is essential
- Know system’s limits and capabilities
- Contingency plans
- Radios, messengers, megaphones
- Universal signals = “X”, 3 of anything
How do you triage?
- Two patients may warrant a triage decision
- Walking wounded
- Evaluate each patient
- Four categories
- Repeat triage process
List the pitfalls associated with these environment and conditions
- Underestimating the situation
- Refusal to adapt
- Inadequate preparation
- Failure to protect self and facility
Summary
- Any location can become an austere or hostile environment.
- ABCDE is an organized approach to the patient.
- Use all available resources.
- Planning and flexibility are critical – know the options.
- “Do the greatest good for the greatest number.”
