Advanced Trauma Life Support ATLS Student Course Manual 2018

278
APPENDIX C n Trauma Care in Mass-Casualty, Austere, and Operational Environments
managed by a plan that controls access until they are
acceptably vetted. Joining medical assistance teams in
advance of events prevents this difficulty.
Special and vulnerable populations include children,
the elderly, the obese, those with psychiatric illnesses,
and patients on home dialysis or ventilators. Declaration
of a disaster or emergency by a responsible official
suspends many healthcare regulations. Facilities
must plan to accept trauma patients in disasters even
if they are not a trauma center. Similarly, burn or
pediatric patients may have to be initially treated in
nonspecialized centers. Loss of utilities or evacuations
may place extra demands on dialysis units, ventilators,
and pharmacy units. Evacuation sleds and disaster
litters must be able to cope with obese patients.
Multidimensional injuries are complex injuries
not normally seen in daily practice that can occur in
disaster. Such injuries may result from high-energy
firearms and high-energy explosives. High-energy
gunshot wounds, such as those from assault rifles, are
created by the linear and cavitating (radial) energy of the
missile and cause tissue devitalization and destruction
outside the actual path of the missile. High-energy
explosives, such as those using military or commercial
grade explosives in improvised explosive devices
(IEDs), cause multidimensional blast injuries across
four mechanisms: primary blast from the supersonic
pressure wave; secondary blast from fragments; tertiary
blast from blunt or penetrating impact with objects
in the environment; and quaternary blast as in burns,
crushing, or infections.
A prominent injury pattern includes multiple
traumatic amputations and traumatic brain injury.
Low-energy explosives, such as gunpowder in pipe
bombs or pressure cookers, tend to produce secondary
blast injuries from fragments for a smaller radius;
however, individuals close to such explosions may
have extensive penetrations and amputations. Wound
management includes hemorrhage control and
debridement of devitalized tissue. Energy tracks along
tissue planes and strips soft tissue from bone. There
may be skip areas of viable tissue with more proximal
devitalized tissue.
Loss of infrastructure and austere environments
can lead to dehydration, disordered body temperature
regulation, and heat injury including heat cramps,
exhaustion, and stroke in both staff and patients.
Prevention of heat casualties includes acclimation
for 3–5 days, alternating work and rest cycles, and
emphasis on regular fluid and electrolyte replacement
(see Chapter 9: Thermal Injuries). Decontamination
and security teams are especially vulnerable.
Psychosocial issues dominate in long-term recovery
from disasters and can be more pressing in austere
and conflict environments. Healthcare providers are
at risk for psychosocial stress disorders from a disaster;
such stress can be attenuated through awareness, good
communications, and debriefings. Healthy behaviors
and organizational practice can improve personnel
resiliency before disaster occurs. Monitoring your
team and yourself for signs of acute stress reactions
is important; appropriate good humor, breaks, and
reassurance can boost morale.
Challenges of OpeRAtional,
Austere, and Resource-
ConstRAined Environments
While ATLS has formed the critical foundation of care
for the injured patient in modern civilian and military
environments, the experience during prolonged
conflicts in Iraq and Afghanistan has also dictated
military-specific modifications to standard ATLS
principles and practice due to the multiple unique
and challenging aspects of providing trauma care in
this severely resource-poor environment. Additional
factors include operating in an environment with
the continuous threat of hostile action, limited basic
equipment and personnel capabilities, limitations
in the supply and resupply chains, lack of the
full range of modern diagnostic and therapeutic
technology (e.g., CT scanners, MRI, angiography), and
a significantly degraded or even nonexistent local
healthcare infrastructure.
The operational or austere environment presents a
wide variation in threats, injuries, human resources,
and medical materiel availability that all must be
considered when planning and executing trauma and
other healthcare operations. Additionally, many of
these same challenges may be applicable to civilian
trauma care in the remote environment, although
typically to a lesser degree. n TABLE C-1 compares the
factors that impact trauma care in the civilian urban,
civilian rural, and operational/disaster environments.
Security and Communication
The tactical situation in any constrained environment
is highly dynamic, resulting in varying degrees of
threat. Both internal and external security concerns
must be considered for the protection of both staff
and patients. Measures may need to include increased
physical plant security with armed personnel or police
presence depending on the environment and situation,
as well as restrictions in facility access, screening, and
identity verification of staff, patients, and visitors, and
the searching of vehicles and personnel for weapons.
n BACK TO TABLE OF CONTENTS