Wilderness Medicine Emergency SOAP Note Scene: Safe? How many? How bad ? MoI for spine? EVAC Numbers: 628.521-1510, RedPoint Emergency - AAC Method of Injury: Secure head/neck Look/Ask/Feel Patient ABCDE Stop + Fix SUB Name:
Age:
Sex: M/F Chief Complaint:
Airway: Breathing: Disability/decision (If no MoI):
_________Circulation/Blood Sweep:__________________ Env/ Exposure:_
________ ____,
Tattoo /Med-A-Lert: ______________________ Head-to-Toe Exam revealed: OBJ Vitals
Time Alert (Person/Place/Time/Event) Level of R +O__ ___+O__ HR x4= x4= RR x2= x2= kin olor emp oisture S C T M
/Verbal/Pain/Unresponsive ___+O__ ___+O__ x4= x4= x2= x2=
Reg/Irr : Strong/Weak Labored/Unlabored: Shallow/Deep
Include signs in the objective information. Make sure to also include symptoms in your notes as well. SX: Allergy: What: Exposure? Y/N/Unk Reaction: Tx: Medications: Name: For: Last Time Taken: Name: For: Last Time Taken: Name: For: Last Time Taken: Include dosage questions in the medications section: what, when, why, how much, did you have it today Hx: has this happened before, do you see a doctor on a regular basis for anything Food/ H2O: Last In/Out: What: PG? Y/N/Unk Blood Type, and Rh factor, if known: _____ Events: Recent Illness/Injury: events of the last 48 to 72 hours
Output Color/Consistency:
Focused Spine Assess: A+ O 3 /4 N/Y→ Sober? N/Y→ Free from distraction (pain): N/Y→ CirculationSensationMovement: N/Y (in all 4 extremities)→ Free of Spine Pain on palpation? Y/N (if yes to all then OK to move or release head) ASSESS: Based on MoI, Possible Possible PLAN, TX:
EVAC PLAN: ANTICIPATED PROBLEMS
Possible Possible
TX Tips: Mild head injury: Amnesia A=O2,3,4→Nausia→Headache→Dizzy→Tired→Vomit OK to sleep, but say remember “fuzzy dinosaur” and then wake every 20’ & ask what nonsense phrase was used Disoriented Irritable Combative head dark color behind ears/raccoon eyes/ might want to include evacuate with any decrease in LOR Sx as above Tx: monitor ABCs/backboard/elevate head 6-8”/EVAC Shock: A+O3,4 (unless otherwise explained)/^HR/^RR/pale+cool+clammy = Compensatory | O↓/agitated/HR↓/RR^/PCC = Decomp | Causes: dehyd/ bleeding. Tx: find and treat the underlying cause control bleeding/maintain airway/calm/ warm/elevate legs12”/fluids in extended situations. CPR: 2 breaths; √ pulse; 30 comp+2br (rept 5x ); re √ pulse/resp Diabetes: Give sugar Abdominal EVAC? Abdominal pain+ S/SX of shock+ Blood in vomit/,urine/feces+ Continuous pain>24O+ Localized gut pain, rigidity/guarding/tenderness, Pain on movement, Nausea/ vomit/ runs causing dehydration or lasting >720,Fever >1020, S/SX of PG (any of these individually should constitute an evacuation Musculoskeletal Test: Look/Ask/Feel→ CirculationSensationMovement→ Passive RoM → Active RoM → Bear weight?→ Unstable TX: HyRICE : Hydrate, Rest, Ice , Compress, Elevate. (NSAID) TX for “unusables” & fracture: Traction → normal position STOP Traction if resistance or marked increase in pain • Splint: rigid , padded. Immobilize joints above & below fracture ( Bones above & below joint injury) • Splinting: Simple/Padded/Adjustable/fingers-toes available • Monitor CirculationSensationMovement before and after splinting For open fracture: Irrigate and dress 1st! Start antibiotics! TX for dislocations: Reduce ASAP+ Slow, steady traction-in-line. Relaxation is key+ HyRICE , work ROM 3x/day this should not be done before consulting a physician for a first time dislocation EVAC: ↓ CirculationSensationMovement, unusable & 1st time dislocations. Wounds Control bleeding Pressure & elevate; pressure on injury point Tourniquet: loosen/ retighten if needed these can be left in place for 2 hours without damage, if you are applying a tourniquet to a wound you should be planning an evacuation for this patient Prevent infection: clean it! Soap / H2O around wound Remove foreign matter; scrub abrasions if needed Pressure irrigate- only H2O Dress & bandage; gaping>1/2” pack w/damp gauze Promote healing Puncture: leave and stabilize in place Remove if: in face-cheek, extremity, cold metal from body core EVAC: Impaled, Packed, Dirty/contaminated / bites, cosmetic, in joints/genitals Heat Exhaustion: A+Ox4, HR/RR↑↓, SCTM: hot/red or pale/cool/clammy or dry TX: cool pt/salty foods H2O/Electrolytes Stroke: Change in LoR (- sign) Disoriented Irritable Combative head, SCTM: red/hot/dry this can vary, may be red/hot/moist, pale/hot/dry. TX: rapidly cool pt Life threatening: EVAC Cold DO NOT RUB frost-nip Mild: “the Umbles” poor motor skills Moderate: ↓LoR (bad sign) uncontrolled shiver, ↑ Umbles Severe: NO shiver, stupor/unresponsive, NO CPR Life threatening: EVAC Tx: warm/dry/no wind/warm food & drink/exercise if able, heat packs, hypo-wrap Frostbite Rewarm in 1060 F H2O/ H2O in wrapped bottles in sleeping bag in groin, arm pits/or skin-to-skin Rev. 30 June 2022, Chris E. Stout