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2Mosby items and derived items © 2010 by Mosby, Inc. an affiliate of Elsevier Inc.
Learning Objectives
Discuss common mechanisms of injury in the farm setting
Explain the differences in approach to crush injury compared to laceration injury
Discuss the causes and management of compartment syndrome
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Learning Objectives (Cont’d)
Explain urgency of caring for a patient who received a hydraulic injection injury
Describe how to recognize organophosphate poisoning
Identify the hazards associated with farm-confined spaces and the risks posed to potential rescuers
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Introduction
Farm unique responses Unique equipment Specialized
chemicals Long response
times typical Often long delays
between injury anddiscovery of the injured
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Introduction (Cont’d)
Farm hazards Chemicals and hazardous materials Toxic environments Confined spaces Injuries involving animals Health conditions caused by dusts, molds,
animal diseases
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Tractor Emergencies
Overturns Half of all farm
deaths Must stabilize
tractor Tractor fluids Nonstandard
engine shut off Power take-off
suddenly stopped, significant torque
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Tractor Emergencies (Cont’d)
Crush syndrome Result of
compressive injury Muscle cells die
and release toxins Restored blood
flow has fatal effect on heart and kidneys
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Tractor Emergencies (Cont’d)
Crush syndrome Epidemiology and demographics
• Few data available• Rarely investigated
History and physical findings• Suspect crush syndrome when
large muscle mass has been compressed for >1 hour Patient trapped >4 hours with compromised circulation
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Tractor Emergencies (Cont’d)
Crush syndrome Differential diagnosis
• Chest injuries and internal bleeding common• Crew safety
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Tractor Emergencies (Cont’d)
Crush syndrome Therapeutic interventions
• Treat life-threatening airway, respiratory, and circulatory injuries
• Medications administered prior to extrication• IV therapy 1–1.5 L/hr NaCl• Sodium bicarbonate 50–100 mEq 20 minutes before
extrication• Albuterol• Glucose • Morphine
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Machinery Emergencies
Become familiar with equipment Pinch points Wrap points Shear points Crush points Pull-in points
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Machinery Emergencies (Cont’d)
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Machinery Emergencies (Cont’d)
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Machinery Emergencies (Cont’d)
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Machinery Emergencies (Cont’d)
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Machinery Emergencies (Cont’d)
Compartment syndrome Pressure within closed muscle compartment Exceeds perfusion pressure and prevents
blood flow Impairs nerve signals Physical findings
• Pain disproportionate to injury • Skin appears taut and shiny• Feels tingling or burning sensation • Distal tissue may be cyanotic, numb, and cold
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Machinery Emergencies (Cont’d)
Compartment syndrome Therapeutic interventions
• Not corrected in field• Treat all associated injuries• Injured extremity should be kept at heart level• Be alert for crush syndrome
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Machinery Emergencies (Cont’d)
Hydraulic injection injuries Pinhole high-
pressure hydraulic leaks can penetrate clothing and skin at up to 7000 psi
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Machinery Emergencies (Cont’d)
Hydraulic injection injuries Injection causes
• Physical distention of tissue Vascular compression Ischemic necrosis Gangrene
• Chemical irritation Inflammation Inflammatory edema Vascular compromise
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Machinery Emergencies (Cont’d)
Hydraulic injection injuries History and physical findings
• Injection site appearance not remarkable• Progressive swelling and inflammation• History of hydraulic repair is the key to determination
Therapeutic interventions• Cold compresses• Elevation
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Chemical Emergencies
Types of farm chemicals Insecticides Herbicides Fungicides Rodenticides Fertilizers Cleaners Disinfectants Sanitizers Fuels
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Chemical Emergencies (Cont’d)
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Chemical Emergencies (Cont’d)
Types of farm chemicals Many are nerve agent derivatives Cholinesterase inhibitors
• SLUDGE-BBM
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Chemical Emergencies (Cont’d)
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Chemical Emergencies (Cont’d)
Routes of exposure Inhalation Ingestion Absorption Injection
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Chemical Emergencies (Cont’d)
Organophosphates and carbamates Attack the nervous system Inhibit cholinesterase Easily absorbed through the skin Early signs
• Runny nose• Salivation• Wheezes
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Chemical Emergencies (Cont’d)
Organophosphates and carbamates Therapeutic interventions
• Appropriate personal protective equipment (PPE)• Airway management• If using RSI, avoid succinylcholine• Atropine
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Chemical Emergencies (Cont’d)
Organochlorines Contain chlorine and carbon Found in herbicides, insecticides, fungicides,
industrial chemicals Some are carcinogenic
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Chemical Emergencies (Cont’d)
Organochlorines History and physical
findings• Abrupt onset• Affects CNS • confusion• Tremors• Headache
• Dermal irritation• Respiratory problems• Dizziness• Nausea• Facial paresthesia• Seizures, coma
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Chemical Emergencies (Cont’d)
Organochlorines Therapeutic interventions
• No specific antidote available• Manage life threats identified• Manage airway • Painful stimulus can trigger seizures• If ingested consider activated charcoal• Cardiac monitoring
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Chemical Emergencies (Cont’d)
Bipyridil herbicides Family of pesticides that includes Paraquat
• Highly toxic• Symptoms take several hours to occur• Slow painful progressive toxicity• Death from respiratory failure• Builds up surfactant-producing cells in lungs and
kidneys• Do not give O2
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Chemical Emergencies (Cont’d)
Bipyridil herbicides Ingestion most common route Absorbed Inhaled
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Chemical Emergencies (Cont’d)
Bipyridil herbicides Due to the toxicity, Paraquat has additives
• Blue dye • Strong odorant • Agent to cause vomiting
Large ingestion results in:• Immediate pain and swelling of mouth and throat• Nausea• Vomiting• Abdominal pain• Diarrhea
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Chemical Emergencies (Cont’d)
Bipyridil herbicides Therapeutic interventions
• Decontamination• Supportive care• O2 if patient is having respiratory distress• IV fluids for potential dehydration
Patient and family education• Restricted pesticide in the United States• Must be licensed to apply
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Chemical Emergencies (Cont’d)
Patient assessment Goals
• Remove patient from chemical• Remove chemical from patient
Zones• Hot zone• Warm zone• Cold zone
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Chemical Emergencies (Cont’d)
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Chemical Emergencies (Cont’d)
Patient assessment Ensure open airway Adequate breathing Stable breathing but cardiopulmonary or
neurological deficit, give O2 Circulation, CPR if necessary Control bleeding Assess pulses and BP IV access Assess neurological status
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Confined Space Emergencies
OSHA definition Large enough for someone to enter Limited egress Not designed for continuous occupancy
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Confined Space Emergencies (Cont’d)
Silos Used to ferment
feed• Creates heat• Creates gasses• Decreases O2
concentration Some are O2
limiting
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Confined Space Emergencies (Cont’d)
Silos Silo filler’s disease
• Results when exposed to silo gas: nitrogen oxides (NOx)
• Low concentration NOx commonly inhaled• Moderate concentration NOx inhaled without
developing immediate symptoms• High concentration NOx can kill in minute
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Confined Space Emergencies (Cont’d)
Silos Silo filler’s disease
• History and physical findings In lower concentration mild irritation to upper airway Higher concentration may render worker unable to
leave
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Confined Space Emergencies (Cont’d)
Silos Silo filler’s disease
• Presentation for mild exposure Ocular irritation Cough Possibly dyspnea Fatigue Nausea Vomiting Cyanosis Vertigo Drowsiness
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Confined Space Emergencies (Cont’d)
Silos Silo filler’s disease
• Later signs/symptoms Pulmonary edema Bronchiolitis obliterans Progressive inflammation of lung tissue High concentration Immediate distress Collapse and death in minutes
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Confined Space Emergencies (Cont’d)
Silos Silo filler’s disease
• Differential diagnosis Hypersensitive pneumonia Toxic organic dust syndrome
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Confined Space Emergencies (Cont’d)
Silos Silo filler’s disease
• Therapeutic interventions Remove from environment O2 Bronchodilators Assisted ventilation as necessary
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Confined Space Emergencies (Cont’d)
Silos Silo filler’s disease
• Patient and family education Farmers must understand hazards associated with
newly filled silos Once filled, no entry for 2 weeks Doors closed to prevent NOx from running down chute Before entering, open from ground with rope Detector tubes
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Confined Space Emergencies (Cont’d)
Silos Other silo gases
• Carbon monoxide• Methane• Present in small
quantities• Silo fires gases• Fresh air• O2• Ventilating silo
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Confined Space Emergencies (Cont’d)
Manure storage gases Ammonia
• Irritant Hydrogen sulfide
• More hazardous• Rotten egg odor
Gasses in higher concentration when manure pit is turned over
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Confined Space Emergencies (Cont’d)
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Confined Space Emergencies (Cont’d)
Manure storage gases Lower level
• Irritated mucous membranes• Irritated respiratory system• Wheezes• Headaches
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Confined Space Emergencies (Cont’d)
Manure storage gases Higher levels
• Acute symptoms• Confusion • Coughing• Dyspnea• Pulmonary edema• Cyanosis• Vertigo• Nausea• Vomiting
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Confined Space Emergencies (Cont’d)
Manure storage gases Extreme concentration
• Cardiopulmonary arrest• Myocardial infarction• Seizures
Differential diagnosis• Asthma• Bronchitis• CO toxicity• Cyanide toxicity
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Confined Space Emergencies (Cont’d)
Manure storage gases Therapeutic interventions
• Remove from environment• Intubate if necessary• Oxygenate• Treat with bronchodilator if necessary• Treat pulmonary edema if necessary
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Confined Space Emergencies (Cont’d)
Scene size-up considerations General silo size-up
• What is the crop inside the silo?• When was the last load put into the silo?• How full is the silo?• How long was the victim inside?• How is the silo unloaded?• Is the power to the silo unloader shut off? • Can the silo blower be turned on?
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Confined Space Emergencies (Cont’d)
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Confined Space Emergencies (Cont’d)
Scene size-up considerations General manure storage size-up
• Has farmer been agitating the manure pit?• Is ventilation of the space possible?• Is the power to pumps off?• Do we have the training, skills, and equipment to
enter? If not, from where will the appropriate responders be dispatched?
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Summary
Managing emergencies on the farm often requires modified procedures, protocols
Most farms use at least one tractor daily; tractor overturns result in half of all farm deaths
Crush injury syndrome can be seen in farm trauma situations because of the length of time the person is often entrapped
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Summary (Cont’d)
Numerous hazard points on farm machines can cause severe entanglement that can challenge even seasoned rescue technicians
Power take-off entanglements can result in severe crushing injuries and acute amputations
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Summary (Cont’d)
Hydraulic oil pressure normally 2000 psi, can exceed 7000 psi through a pinhole leak; fluid can easily penetrate the skin and cause serious complications
Hazardous materials are present on farms to which farmers, their families, and employees can be exposed Some materials are derivatives of nerve agents
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Summary (Cont’d)
Many areas on farms are considered confined spaces by OSHA definition; emergency responders must recognize confined spaces and follow OSHA confined space standards when managing these emergencies
Emergency responders must recognize the potential for deadly gases generated inside silos and manure storage