Welcome to the Trauma Alert Education Newsletter brought to you by Beacon Trauma Services. Edition 6
Trauma Down on the Farm
Source: - https://tinyurl.com/y4rt86y5
Farming Facts Trauma is the leading cause of injury, disability, and death on farms. There are approximately 2 million full time workers employed in agriculture in the United States. In 2018, 416 farmers died in the United States from a work related farm injury. In 2018 in Indiana there were 34 farm related fatalities across the state. o This is 18% higher than the average number of fatalities documented annually since 1970. No specific factor(s) has been identified for the increase. Each year approximately one out of every nine Indiana farms experiences a farm work- related injury that requires medical attention. Two percent of reported farm injuries result in permanent disability. Many of these incidents are not reported in the media, and there is no requirement to report such incidents, including severe injuries, to any official data base. The need remains for a more comprehensive trauma registry that includes farm-related injuries. This could be helpful in targeting prevention efforts at high-risk activities.
There are approximately 450,000 youth under the age of 20 working on farms across the United States. o Every day about 33 children are injured in agricultural related incidents. o About every three days, a child dies in an agricultural related incident. o Of the leading sources of fatalities among youth, 25% involved machinery, 17% involved motor vehicle crashes, and 16% were drownings. Ou
U.S. Agriculture death by source U.S. Agriculture death by event Source Percentage of Event Percentage deaths of deaths Tractors 37 Overturning 25.8 Trucks 9.6 vehicle/machinery Harvesting 4.4 Fall from or run over by 7.3 machinery vehicle/machinery Mowing machinery 3.7 Caught in running 6.8 Animals 3.5 equipment Other ag machinery 3.2 Struck by falling object 5.7 Ground 3.0 Run over 5.2 Loaders 1.8 Fall to lower level 4.2 Trees/logs 1.8 Struck by rolling objects 3.3 Other 29.3 Assault by an animal 3.2 Purdue.edu, 2018 Suicide 2.2 Caught in collapsing 2.0 material Other 3.4 U.S. fatalities by age Purdue.edu, 2018 Age Percentage 15-19 10.2 t very 20-24 14.7 three Indiana farm related deaths 25-34 14.1 days, by county 35-44 17.1 a County Ranking 45-54 21.2 child Elkhart 1st 55-64 31.9 ies in Lagrange 2nd 64+ 65.9 an St. Joseph 3rd Purdue.edu, 2018 Greene 4th Dubois 5th Franklin 6th agricylturellen Vehicleuggy collision 2 Purdue.edu, 2018 0 Total 40 cription
Source: https://tinyurl.com/y5b2htog
Indiana is considered a rural state so the chances of being injured in the country, far away from a hospital and a trauma center, are greater. o The green and yellow areas indicate a rural area of the state. Each day 200 farmers suffer lost work time due to an injury. One in twenty of these “daily accidents” result in permanent impairment. More than half of those injured on a farm die before reaching a hospital or physician.
Source: https://tinyurl.com/y3qvdhug When discussing farming hazards and trauma most people think of the obvious physical injuries from equipment like lacerations, de-gloving, and amputations. However, there are many more hazards that are related to farming that aren’t often thought about or discussed. Farmers also have hazards from chronic health conditions, animals, the environment, vandals, economic, and mental/stress disorders. Equipment Hazards
Source: S. Bobeck, personal photo, October 10, 2019
Amputations, lacerations, degloving, and crush injuries
Farm equipment has several points of hazard that can cause significant, severe injuries if the farmer comes in contact with or is caught in the equipment. Some of those hazards are listed below: o Sheer/cutting points are located in augers with the edges moving rapidly together to cut the crops. o Pinch points are located in belts, gears, and chains with two objects moving together in a circle. o Crush points are located on hitches and equipment connections used to secure or pull two pieces of equipment together. o Pull in points are mechanisms that are designed to take the crops from the field into the machine to be processed. They include combine headers, windrow pickups chopper headers, and grinders. . The machinery can become clogged with the crop and the farmer commonly tries to pull on the stalks to dislodge the clog and then is pulled into the machinery while it is running. . The rolls rotate 12 feet per second. It takes 0.3 seconds to react when the material starts to pull through. The stalk and the hand will travel 3.6 feet before the farmer can release the grip on the stalk and by then it is too late. o Wrap around points are exposed rotating shaft used to transfer power from the tractor to another source like an auger or chopper. Below is a photo with the clothes from a farmer wrapped in the power take off shaft (PTO). Luckily, the farmer was able to get free before his body was wrapped in the shaft.
Farmer’s shirt and jacket wrapped up in a PTO shaft
Source: S. Bobeck, personal photo, October 10, 2019 o Tractors account for 50% of all farm fatalities, with rollovers accounting for 60% of those deaths. Rear over turns are less frequent than side rollovers but they are more fatal because typically the farmer is thrown out of the tractor and it rolls over on top of the farmer. . Factors that increase injuries and death from a tractor are: uneven terrain, being thrown from the tractor, collisions with automobiles, unsafe passenger riding practices, working on running tractors, falling asleep while driving, and running into ditches or electrical poles. o Combines have rotating blades on the heads that pose the greatest hazard. . The combine has blind spots on the sides and the operator can’t see cars or people that are to the side of the combine. . If the crops and fields are extremely dry during harvest the combine exhaust and belts can become over heated and cause the combine to catch on fire.
Source for both photos: S. Bobeck personal photo, October 10, 2020 Treatment for amputations, lacerations, degloving, and crush injuries
Source: https://tinyurl.com/y3oa3xze Amputation Injuries Crush/Degloving Injuries
• Stop the bleed. Stop the bleed. Take amputated part and place in Pre-hospital care should include wrapping the moistened gauze/cloth. affected area in a moist sterile gauze and initiating Take that and place in a plastic an IV of normal saline. bag. Hospital care should include wound care and Place that bag in a bag containing monitoring for traumatic rhabdomyolysis which ice. occurs from the damaged crushed muscle. Care should be taken not to freeze o Observe for dark, amber colored urine from amputated part. the myoglobin in the damaged muscle Do not place on dry ice. building up in the kidneys. Do not place the part directly on o Aggressive IV fluids are critical to protect the ice. kidneys and aid in eliminating the myoglobin from the system. (ATLS Student Manual, 10th ed., 2018) o IV bicarbonate will help to treat the acidosis.
(ATLS Student Manual, 10th ed., 2018)
Share the road with farm machinery
Source for both: https://tinyurl.com/y25r5t8s
Source: https://tinyurl.com/y25r5t8s Traumatic injuries are only some of the hazards of farming. As trauma providers it’s important to understand that the patient may present with traumatic injuries in addition to other conditions that are directly related to working on the farm. For example farmer’s lung, silo filler’s disease, and toxic gases related to manure pits and chemicals will all produce significant respiratory depression in farmers and may require the farmer to seek emergency care. Grain Bin Hazards
Source for all photos: https://tinyurl.com/y4b8f4uw In the United States, in 2018, eighty farmers were engulfed in grain bins and half of those died. The farmer enters the top of the grain bin to check the temperature and moisture of the stored crop, and to break the crust that forms on top of the crop. Because there is a crust that forms over the top of the corn he thinks that it is safe but there are pockets under the crust that shift and act like quick sand pulling the farmer down into the corn and suffocating the farmer.
Respiratory Hazards
ODTS- Organic Dust Toxic Syndrome- “Farmer’s Lung”
Source: https://tinyurl.com/y3uy5cg5
An inflammatory response of the airways after prolonged and repeated exposure to high concentrations of crop dust, spores, and contaminated moldy grain and hay. 30-40% of farmers will be affected by it and more than half will develop chronic “Farmer’s Lung”. Acute symptoms of chills, malaise, body aches, dyspnea, dry cough, headache, rhinitis, conjunctivitis, tachycardia, and fever >100 degrees may appear 4-12 hours after exposure and can last several weeks. o Labs may show an elevated WBC. Treatment is directed toward treating the symptoms. Prevention is directed to educating the farmer to wear a filtered mask when coming into contact with any of the toxic substances.
Silo Hazards
Source: https://tinyurl.com/y4e9h9ro Silo gases are formed by the natural fermentation of chopped silage after it’s placed in the silo. The greatest danger is 12-60 hours after filling the silo because Nitrogen Dioxide gas is formed from the silage during this period. o The gas has a strong bleach like odor and produces low lying yellow, red, or dark brown fumes which can cause severe irritation to the nose, throat, and lungs. Prolonged and repeated exposure can result in Silo Fillers Disease.
Silo Fillers Disease
Source: https://tinyurl.com/y4e9h9ro A pulmonary disease from exposure to the oxides of the nitrogen in silo gases. The nitrogen oxide binds with hemoglobin which impairs oxygen delivery and gas exchange producing hypoxia. In the acute stage the patient will have moderate to severe respiratory distress, hypotension, and metabolic acidosis. In the chronic stage patients can suffer relapses and pneumonia 2-6 weeks after inhalation. There have been reports of farmers dying in their sleep due to severe fluid collecting in their lungs after exposure. Treatment is directed towards airway management and treating the symptoms.
Manure Pit Hazards
Source all photos: https://tinyurl.com/y2gc3cm5 Manure pits are used to collect the manure from livestock and then it is spread over the fields as fertilizer. Potential hazards occur when people get too close to the edge and fall in and drown, or they are overcome by toxic gases.
Breakdown of manure pit gases
Source all photos: https://tinyurl.com/yy9oj5th o Methane- lighter and is on top; highly flammable. o Ammonia- produces cough and SOB. o Carbon Dioxide- decreases your oxygen levels and causes hypoxia. o Hydrogen Sulfide- heavier than air, highly toxic to humans, attacks at cell level, and causes severe acidosis. o If the person survives, treatment is to support the airway and breathing and reverse the acidosis with Amyl Nitrate (nasally) or Sodium Nitrate (IV) and possibly a hyperbaric chamber.
Chemical Hazards Organophosphate
Organophosphate is a chemical used on the crops to kill pests and weeds. Signs of toxicity can include the following:
PUDDLES SLUDGEM DUMBELS P= Pinpoint S= Salivation D= Diaphoresis/Diarrhea U= Urination L= Lacrimation U= Urination
D=Diarrhea U= Urination M= Miosis
D= Diaphoresis D= Defecation B= Brady/bronchospasm L= Lacrimation G= GI Upset E= Emesis E= Excretion E= Emesis L= Lacrimation S= Salivation M= Miosis S= Salivation CNS = Anxiety, Seizures, Confusion
Source: https://tinyurl.com/y6fykvla
o Treatment for Organophosphate exposure is symptomatic and can include: . Atropine to treat the bradycardia & 2 PAM for respiratory muscle weakness. . Irrigate eyes with copious NS/LR and wash the skin with soap and water. . Administer Valium/benzo’s for seizures. . If intubating using Succinylcholine, its duration will be 40 minutes longer than usual.
Anhydrous Ammonia
Source for all photos: https://tinyurl.com/yy7je2vu Anhydrous Ammonia is a nitrogen fertilizer that is a colorless gas with a sharp pungent odor. It is stored in highly pressurized tanks that can leak or explode making it very volatile and caustic to anything it comes in contact with. It is often stolen to make meth. Anhydrous means “without water” and when the gas comes in contact with moisture like skin, lungs, and mucous membranes it reacts immediately causing burns, severe respiratory distress, blindness, seizures, and CNS disturbances. Treatment is symptomatic with airway management, copious flushing with normal saline, and treatment for burns to the eyes, skin, and lungs.
Domestic/Wild Animal Hazards
One in every six farms have animals and livestock. In 2018, there were more than 75,000 injuries and 375 deaths related to kicking, biting, goring, trampling, stomping, and crushing from livestock. Animals have color blindness, poor depth perception, and a natural tendency to move from dimly lit areas to a lighter area. They are sensitive to sudden movements and have blind spots that should be avoided when approaching or caring for them.
Source: https://tinyurl.com/y3gzgnq2
70 year old male kicked by a large work horse. Multiple rib fractures and pulmonary contusion.
A pulmonary contusion is a bruising of the lung caused by thoracic trauma. Blood and other fluids accumulate in the lung tissue, interfering with ventilation and potentially leading to hypoxia. In adults, a pulmonary contusion is most often encountered with rib fractures, and it is the most common potentially lethal chest injury. Clinical presentation may include: dyspnea, tachypnea, hemoptysis, ineffective cough, chest pain, chest wall contusion, rib fractures, and worsening ABG as the edema progresses. The resultant respiratory failure can be subtle, developing over time rather than instantaneously. Limited ventilator reserve may predispose the older adult patient to early respiratory failure. o The “bruise” can blossom 24-72 hours post injury causing significant respiratory compromise.
• Treatment involves ensuring adequate oxygenation, judicious/limited administration of fluids, and administering analgesics to improve ventilation. • Careful assessment of the patient’s respiratory rate, arterial oxygen saturation, and work of breathing will indicate appropriate timing for intubation and ventilation, should it be necessary.
/13 A llen Remember-Safety First! AND If you ate today thank a farmer!
Source: S. Bobeck, personal photo, August 10, 2019
Test Your Knowledge
n1Source: https://tinyurl.com/yaq4y9qk 1. Care of a traumatic amputation injury should include which of the following? a. Wrap part in moist gauze and place in a bag. b. Place the bag containing the part on ice. c. Place part directly on ice or dry ice. d. A and B only
2. Which of the following are assessment indicators of a pulmonary contusion? a. Dyspnea, tachypnea. b. Hemoptysis, chest pain. c. Worsening ABG. d. All the above
3. Which of the following are signs of Farmer’s Lung? a. Fever >100 degrees b. Shortness of breath c. Achiness, headache d. All of the above
Answers at the end
Recognition/Thank You
Emergency Nurses Week- October 11-17 Emergency Nurses Day- October 14 National Physical Therapy Month American Pharmacist Month Pharmacy Tech Day- October 16 Breast Cancer Awareness Month Medical Assistant Week- October 15-19 Pediatric Nurses Week- October 5-9 National Case Management Week- October 11-17 Bosses Day- October 16 National Farmers Day- October 12 Respiratory Therapy Week- 25-31 work We are in this Together!
Source: https://tinyurl.com/y9qy28c6 Test your knowledge Answers-
1. D 2. D 3. D
Resources: The Indiana Agrability Project is a collaboration between Purdue extension and Breaking New Ground (BNG). It provides a resource center for disabled farmers for financial assistance after an injury and connections to adaptive devices so they can continue working on their farms. They can be contacted at 1-800-825-4264 or www.breakingnewground.org
References Agricultural Safety Report. (2020, September 21). Retrieved from https://www.cdc.gov/niosh/topics/aginjury/default.html Indiana Farm Fatality Summary Report. (2020, September 21). Retrieved from https://extension.purdue.edu/INPREPared/wp-content/uploads/2019/09/2018-Indiana-Farm- Fatality-Summary.pdf Farming injury database. (2020, September 21). Retrieved from https://www.purdue.edu/newsroom/releases/2019/Q3/agricultural-production-one-of- indianas-most-hazardous-occupations.html Most Common Farming Hazards. (2020, September, 21). Retrieved from https://www.agrinews- pubs.com/ Advanced Trauma Life Support Student Manual, 10th ed., (2018). Chicago. American College of Surgeons.
For questions or future submissions contact Stacie Bobeck MSN, RN, CEN, CPEN, TCRN, SANE-A Beacon Trauma Educator and Outreach/Injury Prevention Coordinator at [email protected]