ATLS in The Austere Environment

Question 1

Learning Objectives

Answer 1

• 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.

Question 2

Define ‘Austere environment’

Answer 2

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.

Question 3

State one Austere environment

Answer 3

• Military: Limited resources
• Wilderness: Extremes of the environment (Hella cold or hot)

Question 4

Describe the military aspects of Austere environment

Answer 4

• Massive wounds from explosions
• Haemorrhage control
• Back to basics – ABCs and debridement
• Seek additional training

Question 5

List some hostile environments

Answer 5

• Disasters including:
• Natural
• Manmade: War, Industrial, Terrorism

Question 6

List some considerations when travelling to Austere or hostile environments

Answer 6

• Personnel
• Equipment and supplies
• Communication
• Transportation

Question 7

What does hospital based patient care typically entail?

Answer 7

• Involves personnel: abundant consultants
• Sophisticated resources and technology
• Availability of supplies
• Shelter
• Evacuation and transport

Question 8

How do you prepare & plan on travelling to an Austere environment?

Answer 8

• Travel to an Austere Environment
• Stay healthy and fit
• Plan: Water, food, clothing, shelter, Communication
• Be invited as part of a team
• Personal effects in order

Question 9

How do you prepare & plan on travelling to an Hostile environment? (PART 2)

Answer 9

• Hospital Environment
• Regional plan with fire, rescue, police, civil, military, and hospital personnel
• Threat assessment
• Equipment and supplies
• Emergency sources for power, water, and supplies

Question 10

How do you prepare & plan on travelling to an Hostile environment? (PART 2)

Answer 10

• Hospital Environment
• Detection and treatment of toxic agents
• Protective clothing
• Respiratory protection
• Regular drills and practices

Question 11

What are the treatment options for Airways?

Answer 11

• Standard approach: Look, listen, feel
• Available resources: Suture through tongue
• Definitive airway: Tactile / digital intubation
• Surgical options

Question 12

What are the treatment options for breathing?

Answer 12

• 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

Question 13

What are the treatment device options?

Answer 13

• 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

Question 14

What are the Treatment Options for Circulation?

Answer 14

• 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

Question 15

List some special circumstances to consider in different environments

Answer 15

• Pain management
• Management of specific injuries
• Preparation for transport
• Environmental extremes
• Communication
• Triage

Question 16

How do we treat “Pain management”?

Answer 16

• Immobilization
• Avoid intramuscular narcotics
• Consider: Oral agents, IV / IM ketamine, Local anesthetics

Question 17

How do we treat “Specific injury management” for the abdomen?

Answer 17

• No CT or FAST
• No tests if no OR
• DPL for triage

Question 18

How do we treat “Specific injury management” for the musculoskeletal system?

Answer 18

• Improvised splints
• Sheet to close pelvis
• Elevate extremity

Question 19

How do we treat “Specific injury management” for burn injuries?

Answer 19

• 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

Question 20

How do we prepare for patient transport?

Answer 20

• Do no further harm
• Find shelter (high ground)
• Move patient as little as possible
• Keep warm and dry
• Anticipate delay in evacuation

Question 21

How do we manage environmental extremes?

Answer 21

• Plan: Clothing, food, fluids, shelter, and activity level
• Cold: Prevent heat loss
• Heat: Correct fluid and electrolyte abnormalities (oral / parenteral)

Question 22

How do we manage communications in these environments?

Answer 22

• Preplanning is essential
• Know system’s limits and capabilities
• Contingency plans
• Radios, messengers, megaphones
• Universal signals = “X”, 3 of anything

Question 23

How do you triage?

Answer 23

• Two patients may warrant a triage decision
• Walking wounded
• Evaluate each patient
• Four categories
• Repeat triage process

Question 24

List the pitfalls associated with these environment and conditions

Answer 24

• Underestimating the situation
• Refusal to adapt
• Inadequate preparation
• Failure to protect self and facility

Question 25

Summary

Answer 25

• 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.”