What would you do here? Chainsaw Injury [WARNING: GRAPHIC IMAGE IN THE POST]

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El Solis

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Hello Everyone!
In addition to the trauma scenarios were the goal is to practice going through a full assessment of the scene and patient, I will be putting out threads with specific issues, like this one that will address a large open wound. Part of the post is to show you what you should/could use to address the injury, part will be to discuss options in relation to gear and treatment, and lastly by being exposed to real pictures of real injuries my hope is that the shock and awe of seeing them decreases for you so that if you are ever faced with something like this you will be less disturbed by the injury and more focused on the care of the patient. As always, if you have any questions please reply here or message me.

Chris


This is an actual chainsaw injury that came into my hospital when I was on call. In this case there was no active arterial bleeding, just a little oozing from the soft tissue and muscle. We did not apply a tourniquet, just packed the wound with Quikclot and I took the patient to the operating room for a washout and closure. They were released from the hospital the next day and at the two week follow up could walk without crutches.

For this post, we will pretend that this occurred while out in the middle of nowhere while the patient was trying to clear a trail. Following the standard procedures of scene assessment and then the ABCs the first step would be to make sure the scene is safe for the rescuers and the patient. This might include making sure the chainsaw is off, that whatever was being cut will not fall on the patient or rescuers, and that no secondary injuries can occur to the patient. Once this is done it is safe to approach the patient and administer care. In all cases, you should address massive bleeding first, then the Airway and Breathing and then once this is done move on to looking for other injuries by exposing the patient (Disability and Exposure/Environment). We won't address or focus on those in this scene.

1st Situation: Unsafe scene with obvious massive bleeding
In this case I would rapidly approach the patient and apply a tourniquet as high above the injury in the groin as possible and then move the patient to a safe area where more definitive care can be done. If you do not have a tourniquet you can try to apply direct pressure to the groin which should occlude the femoral artery but if you have to move the patient it would be impossible to apply enough pressure and move the patient at the same time. In this case you can assess the Airway and Breathing while approaching by calling out to see if they can answer. If the patient can talk then the Airway and Breathing are ok for now. Once the patient is cleared into a safe area, the wound should be exposed, here is where your trauma shears come in to play, and packed with gauze. Quikclot is my choice but regular gauze is fine and then a pressure dressing should be applied. For this I would use an Israeli Trauma bandage but again, a regular ACE wrap is fine. This wound should not be closed in the field. The patient will need to be transported to a hospital. Remember to cover the patient with a blanket during transport to help treat shock.

2nd Situation: Safe scene with obvious massive bleeding
Here I would apply the tourniquet without moving the patient and then start my assessment and follow the same protocol as above.

3rd Situation: Unsafe scene without obvious bleeding
Assess the Airway and Breathing as you walk up to the patient. Here I would move the patient to safe area and then assess the wound by exposing it with my trauma shears and packing it with Quikclot or other gauze and wrap with a pressure dressing. I would not use a tourniquet in this setting unless my packing and pressure dressing failed (blood soaked through). I would then evacuate the patient and monitor for shock.

4th Situation: Safe scene without obvious bleeding
Same as the 3rd situation but I wouldn't move the patient right away.


Take home points:

1. Make sure the scene is safe before rendering definitive care.
2. Tourniquets are perfect for uncontrolled or massive bleeding that needs to be addressed immediately. They are applied as high as possible on the limb that is injured and as tight as possible. If the injury is lower on the limb, you can try to apply a second tourniquet just above the injury and release the one higher up. If you do this I would leave the first tourniquet in place but loose and ready to tighten if the bleeding returns.
3. Do not try to wash the wound or close the wound in the field for a wound this size and depth. Pack and apply pressure and get to a hospital
4. Continue to run through the ABC's even after the wound is treated.
5. Do not be afraid to try something else if the first thing doesn't work (adding a tourniquet or a pressure dressing, adding a second tourniquet, etc)


So....are you and your kit prepared for this?
 

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slomatt

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Bay Area, CA
I'm really enjoying your posts, thank you for taking the time to write them up and share your knowledge.

Is that the muscle being exposed at the bottom of the injury? That picture really drives things home, though I'm surprised at the lack of extensive bleeding.

Two questions:

1) Can you provide more details on why the tourniquet should be applied as high up on the limb as possible? I would have thought it should be applied close above the wound to minimize the amount of the limb that is denied blood flow. I'm definitely interested in learning more here. As a note, I was trained to write the date/time the tourniquet was applied and to not remove it once applied because lactic acid can build up in the limb and cause issues if suddenly released.

2) To date I've avoided adding a clotting agent to my first aid kit because I was told that they can be difficult to later remove. This probably only applies to the older powdered type and not the newer impregnated gauze format. Have you ever run into (or been aware of) issues removing Quickclot from a wound?

To answer your question "are you and your kit prepared for this?"... I think so. I feel that my training has covered similar wounds, and my first aid kit contains the necessary PPE, trauma shears, an Israeli bandage, tourniquet, gauze, other packing materials if needed, and options for compression bandages. That said, I think I'd only have enough to handle one wound of this size, if there were multiple victims I'd have to improvise additional supplies.
 

El Solis

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@slomat

Yes, that is muscle exposed at the bottom of the wound. As for the bleeding, most of the smaller arteries will actually close due to spasm of the muscle in the walls. Once they relax you can get more bleeding. The veins tend to ooze in this location. The major vessels were spared which is another reason there wasn’t much bleeding. That picture was in the ER waiting for surgery so you can see that we don’t have it packed at this time.

Question 1: when you are first addressing bleeding you want to be able to stop it as fast as possible and the best way to do that is closing the biggest inlets. Kind of a one and done approach as you haven’t assessed for other injuries. These locations are as high up into the groin as you can get and same for the arm, at the junction of the chest wall and arm. Once you have control and have assessed the wound AND YOU FEEL COMFORTABLE THAT YOU HAVE APPLIED THE APPROPRIATE PRESSURE DRESSING AND/OR TOURNIQUET TO AN AREA DIRECTLY ABOVE THE INJURY you can slowly back off the primary tourniquet. I personally leave the primary one in place just loose in case the bleeding starts again. You are correct that you should write the time down in military time on the tourniquet because it does matter to us at the receiving end. Not only does lactic acid build up but other toxins and in particular potassium which leaks from the cells as they die builds up and when you release the tourniquet you get what is called the “reperfusion syndrome” which can be fatal. For our purposes once you place a tourniquet you should leave it unless you really feel comfortable releasing it. You are pretty safe up to 6 hours of tourniquet time. If you have a prolonged evacuation time then I would try to get local control of the bleeding so as to release the tourniquet but again, keep it in place just in case. You won’t want it back anyways. Once you use one you should replace it.

Question 2: the issue was/is with the powders. They burn and really stick to the tissues. I’ve had to remove it in the OR and it usually causes more tissue damage than the initial injury. The impregnated gauze works better and is easy to remove. I literally used it yesterday and removed it from a wound today at the bedside without any issue.

As for the patient, with a proper washout and closure they healed well and has a crazy story. This was two weeks out. IMG_2821.jpg
 

slomatt

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Bay Area, CA
@El Solis, I'm glad to see the patient was up and walking that quickly after the incident.

Thank you for the details on tourniquet use and clotting agents. Based on your comments I'm thinking of adding some Quickclot to my first aid kit.
 
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Justin Lee

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Pensacola, FL, USA
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Justin
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Lee
I'm really enjoying your posts, thank you for taking the time to write them up and share your knowledge.

Is that the muscle being exposed at the bottom of the injury? That picture really drives things home, though I'm surprised at the lack of extensive bleeding.

Two questions:

1) Can you provide more details on why the tourniquet should be applied as high up on the limb as possible? I would have thought it should be applied close above the wound to minimize the amount of the limb that is denied blood flow. I'm definitely interested in learning more here. As a note, I was trained to write the date/time the tourniquet was applied and to not remove it once applied because lactic acid can build up in the limb and cause issues if suddenly released.

2) To date I've avoided adding a clotting agent to my first aid kit because I was told that they can be difficult to later remove. This probably only applies to the older powdered type and not the newer impregnated gauze format. Have you ever run into (or been aware of) issues removing Quickclot from a wound?

To answer your question "are you and your kit prepared for this?"... I think so. I feel that my training has covered similar wounds, and my first aid kit contains the necessary PPE, trauma shears, an Israeli bandage, tourniquet, gauze, other packing materials if needed, and options for compression bandages. That said, I think I'd only have enough to handle one wound of this size, if there were multiple victims I'd have to improvise additional supplies.
In response to your questions:

When applying a "hasty" tourniquet to an extremity, we go high and tight. The reason for this is that an artery will get pulled up into the extremity. Imagine the wound is midline between the waist and the knee, the femoral can move a lot. Generally, around two inches is pretty normal. But to ensure that you get compression, you go high. Now, the reason we then place a second tourniquet closer to the wound, is to save as much tissue as possible. This is called the deliberate tourniquet. Once it is tight, you SLOWLY begin releasing the higher tourniquet and re-check for bleeding. The upper tourniquet stays in place, but loose, while the TQ close to the wound in packaged for movement. The reason you put a time on the TQ, or the forehead, is because they can be left on for 6 hours with no issues.
Quikclot is a pain in the sphincter to debried, however, that's a hospital concern, not worth bleeding all the way there. All packing material sucks to remove, but that will be the least of your concern if you need it. I am thinking of doing some short classes/convos at OB events in my local area. Do you think that could be beneficial?
 

Justin Lee

Rank 0

Traveler I

98
Pensacola, FL, USA
First Name
Justin
Last Name
Lee
Hello Everyone!
In addition to the trauma scenarios were the goal is to practice going through a full assessment of the scene and patient, I will be putting out threads with specific issues, like this one that will address a large open wound. Part of the post is to show you what you should/could use to address the injury, part will be to discuss options in relation to gear and treatment, and lastly by being exposed to real pictures of real injuries my hope is that the shock and awe of seeing them decreases for you so that if you are ever faced with something like this you will be less disturbed by the injury and more focused on the care of the patient. As always, if you have any questions please reply here or message me.

Chris


This is an actual chainsaw injury that came into my hospital when I was on call. In this case there was no active arterial bleeding, just a little oozing from the soft tissue and muscle. We did not apply a tourniquet, just packed the wound with Quikclot and I took the patient to the operating room for a washout and closure. They were released from the hospital the next day and at the two week follow up could walk without crutches.

For this post, we will pretend that this occurred while out in the middle of nowhere while the patient was trying to clear a trail. Following the standard procedures of scene assessment and then the ABCs the first step would be to make sure the scene is safe for the rescuers and the patient. This might include making sure the chainsaw is off, that whatever was being cut will not fall on the patient or rescuers, and that no secondary injuries can occur to the patient. Once this is done it is safe to approach the patient and administer care. In all cases, you should address massive bleeding first, then the Airway and Breathing and then once this is done move on to looking for other injuries by exposing the patient (Disability and Exposure/Environment). We won't address or focus on those in this scene.

1st Situation: Unsafe scene with obvious massive bleeding
In this case I would rapidly approach the patient and apply a tourniquet as high above the injury in the groin as possible and then move the patient to a safe area where more definitive care can be done. If you do not have a tourniquet you can try to apply direct pressure to the groin which should occlude the femoral artery but if you have to move the patient it would be impossible to apply enough pressure and move the patient at the same time. In this case you can assess the Airway and Breathing while approaching by calling out to see if they can answer. If the patient can talk then the Airway and Breathing are ok for now. Once the patient is cleared into a safe area, the wound should be exposed, here is where your trauma shears come in to play, and packed with gauze. Quikclot is my choice but regular gauze is fine and then a pressure dressing should be applied. For this I would use an Israeli Trauma bandage but again, a regular ACE wrap is fine. This wound should not be closed in the field. The patient will need to be transported to a hospital. Remember to cover the patient with a blanket during transport to help treat shock.

2nd Situation: Safe scene with obvious massive bleeding
Here I would apply the tourniquet without moving the patient and then start my assessment and follow the same protocol as above.

3rd Situation: Unsafe scene without obvious bleeding
Assess the Airway and Breathing as you walk up to the patient. Here I would move the patient to safe area and then assess the wound by exposing it with my trauma shears and packing it with Quikclot or other gauze and wrap with a pressure dressing. I would not use a tourniquet in this setting unless my packing and pressure dressing failed (blood soaked through). I would then evacuate the patient and monitor for shock.

4th Situation: Safe scene without obvious bleeding
Same as the 3rd situation but I wouldn't move the patient right away.


Take home points:

1. Make sure the scene is safe before rendering definitive care.
2. Tourniquets are perfect for uncontrolled or massive bleeding that needs to be addressed immediately. They are applied as high as possible on the limb that is injured and as tight as possible. If the injury is lower on the limb, you can try to apply a second tourniquet just above the injury and release the one higher up. If you do this I would leave the first tourniquet in place but loose and ready to tighten if the bleeding returns.
3. Do not try to wash the wound or close the wound in the field for a wound this size and depth. Pack and apply pressure and get to a hospital
4. Continue to run through the ABC's even after the wound is treated.
5. Do not be afraid to try something else if the first thing doesn't work (adding a tourniquet or a pressure dressing, adding a second tourniquet, etc)


So....are you and your kit prepared for this?
Looks delicious. Pretty superficial, but man can those jagged blades make for a gnarly cut. Whoever did those staples did a very nice job. This patient definately needs to be treated for shock. I believe shock to be the worst secondary "injury" in a case like this.
 
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MA_Trooper

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Aaaaaaaaaand this is why I where silly orange husky chaps... Had a friend who was on a job and caught the kick in the neck. was not a great situation. hes fine now.
 
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slomatt

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Bay Area, CA
In response to your questions:

When applying a "hasty" tourniquet to an extremity, we go high and tight. The reason for this is that an artery will get pulled up into the extremity. Imagine the wound is midline between the waist and the knee, the femoral can move a lot. Generally, around two inches is pretty normal. But to ensure that you get compression, you go high. Now, the reason we then place a second tourniquet closer to the wound, is to save as much tissue as possible. This is called the deliberate tourniquet. Once it is tight, you SLOWLY begin releasing the higher tourniquet and re-check for bleeding. The upper tourniquet stays in place, but loose, while the TQ close to the wound in packaged for movement. The reason you put a time on the TQ, or the forehead, is because they can be left on for 6 hours with no issues.
Quikclot is a pain in the sphincter to debried, however, that's a hospital concern, not worth bleeding all the way there. All packing material sucks to remove, but that will be the least of your concern if you need it. I am thinking of doing some short classes/convos at OB events in my local area. Do you think that could be beneficial?
Justin, thank you for the input.

I think the more first aid training that is available to OB members the better.
 
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Overland A Far

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Great thread. Interesting comments on the powder and tourniquet. First aid training is a must for any backcountry adventures or just dealing with serious incidents with family and friends. It can save a family member's life! Prevention goes a long way! Use the personal protective equipment - it's cheap insurance! There are great chainsaw training DVDs put out by Stihl and Husqvarna. An hour long video can save you a lot of grief and work. This situation turned out OK and glad to see he is on the mend. Good luck - not good management!
 

Firemom

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Hello Everyone!
In addition to the trauma scenarios were the goal is to practice going through a full assessment of the scene and patient, I will be putting out threads with specific issues, like this one that will address a large open wound. Part of the post is to show you what you should/could use to address the injury, part will be to discuss options in relation to gear and treatment, and lastly by being exposed to real pictures of real injuries my hope is that the shock and awe of seeing them decreases for you so that if you are ever faced with something like this you will be less disturbed by the injury and more focused on the care of the patient. As always, if you have any questions please reply here or message me.

Chris


This is an actual chainsaw injury that came into my hospital when I was on call. In this case there was no active arterial bleeding, just a little oozing from the soft tissue and muscle. We did not apply a tourniquet, just packed the wound with Quikclot and I took the patient to the operating room for a washout and closure. They were released from the hospital the next day and at the two week follow up could walk without crutches.

For this post, we will pretend that this occurred while out in the middle of nowhere while the patient was trying to clear a trail. Following the standard procedures of scene assessment and then the ABCs the first step would be to make sure the scene is safe for the rescuers and the patient. This might include making sure the chainsaw is off, that whatever was being cut will not fall on the patient or rescuers, and that no secondary injuries can occur to the patient. Once this is done it is safe to approach the patient and administer care. In all cases, you should address massive bleeding first, then the Airway and Breathing and then once this is done move on to looking for other injuries by exposing the patient (Disability and Exposure/Environment). We won't address or focus on those in this scene.

1st Situation: Unsafe scene with obvious massive bleeding
In this case I would rapidly approach the patient and apply a tourniquet as high above the injury in the groin as possible and then move the patient to a safe area where more definitive care can be done. If you do not have a tourniquet you can try to apply direct pressure to the groin which should occlude the femoral artery but if you have to move the patient it would be impossible to apply enough pressure and move the patient at the same time. In this case you can assess the Airway and Breathing while approaching by calling out to see if they can answer. If the patient can talk then the Airway and Breathing are ok for now. Once the patient is cleared into a safe area, the wound should be exposed, here is where your trauma shears come in to play, and packed with gauze. Quikclot is my choice but regular gauze is fine and then a pressure dressing should be applied. For this I would use an Israeli Trauma bandage but again, a regular ACE wrap is fine. This wound should not be closed in the field. The patient will need to be transported to a hospital. Remember to cover the patient with a blanket during transport to help treat shock.

2nd Situation: Safe scene with obvious massive bleeding
Here I would apply the tourniquet without moving the patient and then start my assessment and follow the same protocol as above.

3rd Situation: Unsafe scene without obvious bleeding
Assess the Airway and Breathing as you walk up to the patient. Here I would move the patient to safe area and then assess the wound by exposing it with my trauma shears and packing it with Quikclot or other gauze and wrap with a pressure dressing. I would not use a tourniquet in this setting unless my packing and pressure dressing failed (blood soaked through). I would then evacuate the patient and monitor for shock.

4th Situation: Safe scene without obvious bleeding
Same as the 3rd situation but I wouldn't move the patient right away.


Take home points:

1. Make sure the scene is safe before rendering definitive care.
2. Tourniquets are perfect for uncontrolled or massive bleeding that needs to be addressed immediately. They are applied as high as possible on the limb that is injured and as tight as possible. If the injury is lower on the limb, you can try to apply a second tourniquet just above the injury and release the one higher up. If you do this I would leave the first tourniquet in place but loose and ready to tighten if the bleeding returns.
3. Do not try to wash the wound or close the wound in the field for a wound this size and depth. Pack and apply pressure and get to a hospital
4. Continue to run through the ABC's even after the wound is treated.
5. Do not be afraid to try something else if the first thing doesn't work (adding a tourniquet or a pressure dressing, adding a second tourniquet, etc)


So....are you and your kit prepared for this?
Very well written and informative. Thank you
 

Fozzy325

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@El Solis What do you think of the following suggestions?

1. Elevate the limb
2. Remove boot and check the colour of the toes and pinch test
3. If using a NATO FFD or Israel dressing and blood starts coming through do not remove as you will remove any clotting. Just put another one on top to a maximum of 3. After 3 remove and try again.

While applying a tourniquet remember to allow blood flow every 15 min.
With a sharpie place a “T” on the forehead
4. Check the body in a “Pat” and “check” method to look for more injuries
5. If you know it, start recoding the GCS Glasgow coma scale recording
6. Most important. Keep talking to the casualty and listen to change is response
 

El Solis

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@El Solis What do you think of the following suggestions?

Everything but this part looks good.

"While applying a tourniquet remember to allow blood flow every 15 min."

Once a tourniquet is placed you should really leave it in place until formal, definitive care can be applied. If you had an injury lower on the leg/arm and put the first tourniquet up high on the limb, you could place a second tourniquet lower and then release the upper one. I would not release the tourniquet for blood flow. The tourniquet is there to stop blood flow. Tourniquets are safe for up to 6 hours before you have to worry about tissue loss.
 

slomatt

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@El Solis, in your Trauma Kit video on Youtube you mentioned that you had not found any commercially available trauma kits that met your needs. What do you think of the following? It contains most of the items you recommended, though in a smaller quantity.

https://www.bestglide.com/trauma-kit.html

Bestglide (Adventure Survival Equipment) is a solid company that I have purchased from in the past. The picture on the website is slightly misleading since I think the black bag is an add-on, by default the kit comes in an Aloksak bag.
 

Fozzy325

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Traveler I

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Calgary, AB, Canada
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@El Solis, in your Trauma Kit video on Youtube you mentioned that you had not found any commercially available trauma kits that met your needs. What do you think of the following? It contains most of the items you recommended, though in a smaller quantity.

https://www.bestglide.com/trauma-kit.html

Bestglide (Adventure Survival Equipment) is a solid company that I have purchased from in the past. The picture on the website is slightly misleading since I think the black bag is an add-on, by default the kit comes in an Aloksak bag.
In the Uk there is a company SP services that used when I was in the mountain Rescue. https://www.spservices.co.uk/ I know many paramedic services use them.

There must be a site in the US/Canada just the same. Have a look and you may pick up key words to search by.
 

Plasmajab

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Not sure, but the best thing I kept in the bag was the stuff I can use quickly and effectively. Secondary to that is anything expedient and available. Clean socks seemed to be a common thing I was seeing. When it comes to doing field medicine your limitations are your kit and creativity. Of course in a dire situation. My leg bag was just enough kit to get the cas back to the boat for more advanced care.

And if more then one cas, remember to prioritize and delegate.