Chapter 53 Farm Response 1 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 2 Learning Objectives Explain urgency of caring for a patient who received a hydraulic injection injury Describe how to recognize organophosphate poisoning Identify the hazards associated with farmconfined spaces and the risks posed to potential rescuers 3 1
Farm unique responses Unique equipment Specialized chemicals Long response times typical Often long delays between injury and discovery of the injured Introduction 4 Introduction Farm hazards Chemicals and hazardous materials Toxic environments Confined spaces Injuries involving animals Health conditions caused by dusts, molds, animal diseases 5 Tractor Emergencies Overturns Half of all farm deaths Must stabilize tractor Tractor fluids Nonstandard engine shut off Power take-off suddenly stopped, significant torque 6 2
Tractor Emergencies Crush syndrome Result of compressive injury Muscle cells die and release toxins Restored blood flow has fatal effect on heart and kidneys 7 Tractor Emergencies 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 8 Tractor Emergencies Crush syndrome Differential diagnosis Chest injuries and internal bleeding common Crew safety 9 3
Tractor Emergencies 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 10 Machinery Emergencies Become familiar with equipment Pinch points Wrap points Shear points Crush points Pull-in points 11 Machinery Emergencies 12 4
Machinery Emergencies 13 Machinery Emergencies 14 Machinery Emergencies 15 5
Machinery Emergencies 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 16 Machinery Emergencies 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 17 Machinery Emergencies Hydraulic injection injuries Pinhole highpressure hydraulic leaks can penetrate clothing and skin at up to 7000 psi 18 6
Machinery Emergencies Hydraulic injection injuries Injection causes Physical distention of tissue Vascular compression Ischemic necrosis Gangrene Chemical irritation Inflammation Inflammatory edema Vascular compromise 19 Machinery Emergencies 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 20 Chemical Emergencies Types of farm chemicals Insecticides Herbicides Fungicides Rodenticides Fertilizers Cleaners Disinfectants Sanitizers Fuels 21 7
Chemical Emergencies 22 Chemical Emergencies Types of farm chemicals Many are nerve agent derivatives Cholinesterase inhibitors SLUDGE-BBM 23 Chemical Emergencies 24 8
Chemical Emergencies Routes of exposure Inhalation Ingestion Absorption Injection 25 Chemical Emergencies Organophosphates and carbamates Attack the nervous system Inhibit cholinesterase Easily absorbed through the skin Early signs Runny nose Salivation Wheezes 26 Chemical Emergencies Organophosphates and carbamates Therapeutic interventions Appropriate personal protective equipment (PPE) Airway management If using RSI, avoid succinylcholine Atropine 27 9
Chemical Emergencies Organochlorines Contain chlorine and carbon Found in herbicides, insecticides, fungicides, industrial chemicals Some are carcinogenic 28 Chemical Emergencies Organochlorines History and physical findings Abrupt onset Affects CNS confusion Tremors Headache Dermal irritation Respiratory problems Dizziness Nausea Facial paresthesia Seizures, coma 29 Chemical Emergencies 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 30 10
Chemical Emergencies 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 O 2 31 Chemical Emergencies Bipyridil herbicides Ingestion most common route Absorbed Inhaled 32 Chemical Emergencies 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 33 11
Chemical Emergencies Bipyridil herbicides Therapeutic interventions Decontamination Supportive care O 2 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 34 Chemical Emergencies Patient assessment Goals Remove patient from chemical Remove chemical from patient Zones Hot zone Warm zone Cold zone 35 Chemical Emergencies 36 12
Chemical Emergencies Patient assessment Ensure open airway Adequate breathing Stable breathing but cardiopulmonary or neurological deficit, give O 2 Circulation, CPR if necessary Control bleeding Assess pulses and BP IV access Assess neurological status 37 OSHA definition Large enough for someone to enter Limited egress Not designed for continuous occupancy 38 Silos Used to ferment feed Creates heat Creates gasses Decreases O 2 concentration Some are O 2 limiting 39 13
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 40 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 41 Silos Silo filler s disease Presentation for mild exposure Ocular irritation Cough Possibly dyspnea Fatigue Nausea Vomiting Cyanosis Vertigo Drowsiness 42 14
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 43 Silos Silo filler s disease Differential diagnosis Hypersensitive pneumonia Toxic organic dust syndrome 44 Silos Silo filler s disease Therapeutic interventions Remove from environment O 2 Bronchodilators Assisted ventilation as necessary 45 15
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 46 Silos Other silo gases Carbon monoxide Methane Present in small quantities Silo fires gases Fresh air O 2 Ventilating silo 47 Manure storage gases Ammonia Irritant Hydrogen sulfide More hazardous Rotten egg odor Gasses in higher concentration when manure pit is turned over 48 16
49 Manure storage gases Lower level Irritated mucous membranes Irritated respiratory system Wheezes Headaches 50 Manure storage gases Higher levels Acute symptoms Confusion Coughing Dyspnea Pulmonary edema Cyanosis Vertigo Nausea Vomiting 51 17
Manure storage gases Extreme concentration Cardiopulmonary arrest Myocardial infarction Seizures Differential diagnosis Asthma Bronchitis CO toxicity Cyanide toxicity 52 Manure storage gases Therapeutic interventions Remove from environment Intubate if necessary Oxygenate Treat with bronchodilator if necessary Treat pulmonary edema if necessary 53 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? 54 18
55 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? 56 Chapter 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 57 19
Chapter Summary 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 58 Chapter Summary 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 59 Chapter Summary 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 60 20
Questions? 61 21