The Big Syringe
We like improvised kit; being able to adapt and improvise allows us to overcome obstacles with minimal resources and being flexible enables us to rely less on equipment.
A large (60ml or 50ml) syringe is one of those items that we can use to good effect for a number of jobs.
The following practices are suggested for use by those with relevant training and experience. As with all of our articles, reading alone does not make anyone proficient in any practical skill.
Wound irrigation
Wound irrigation is an effective method of cleaning wounds without the need for antiseptics which have the potential to delay wound healing and cause cell damage. High pressure wound irrigation is optimal at 8-15psi, which is achieved using an 18g or 19g needle or cannula with a large volume syringe. Rather than using needles which have the potential for accidental injection, blunt 'mixing needles' pose no such threat. We recommend an 18g mixing needle combined with a large volume syringe for all wound cleaning in remote environments.
Smaller syringes generate higher pressures which can cause tissue damage and drive bacteria deeper into the wound.
The volume of fluid required for effective wound irrigation varies in supporting literature but is generally agreed that a minimum of 1 litre of clean water (or 100ml per 1 cm of wound) is required.
Find out more about dealing with wounds in remote environments on our Remote First Aid course.
Suction
Being able to clear a casualty's airway is an absolute priority. As a basic rule, we use whatever means possible to do so, including rough handling at the expense of spinal control if no other method exists. As long as the method does not pose a risk of introducing material further into the airway or stimulating the gag reflex, we do it.
In an ideal world we will have suction equipment which allows us to clear fluids whilst maintaining spinal control but if we don't have a dedicated aspirator we can improvise with a large syringe and a nasopharyngeal (NP) airway.
One of the features of a large syringe is the Luer-Lock fitting; a threaded shroud surrounding the tip. This shroud will snuggly accept a size 8mm Nasosafe NP airway and most Portex NP airways. We prefer the Nasosafe variety, being more rigid they offer more control and are less likely to collapse under vacuum when suctioning thick or lumpy fluids.
The normal rules of suction apply so if you don't know what you are doing, get trained before attempting.
We'd like to thank Aebhric O'Kelly of Merit Training who first showed us this and allowing us to share.
Inflating Airways
Several laryngeal and supraglotic airways depend on inflatable cuffs to create a seal. The volume of air required depends on each brand, model and size. Why carry a selection of syringes in your airway kit when one large one will inflate any size?
ET or Laryngeal tube bite block
Bite blocks are used to protect an ET or Laryngeal tube from occlusion or damage if a sedated patient or unconscious casualty were to bite down.
An improvised bite block can be made by cutting off the top inch of the syringe barrel.
Needle Decompression
A large syringe half filled with water can be a useful check for air escaping during needle decompression, especially in a noisy environment.
Improvised Uterine Balloon Tamponade
Postpartum Haemorrage (PPH) is a potentially life-threatening bleed which occurs at the time of placental separation or shortly after. Primary PPH (up to 500ml of blood loss) occurs in 5% of cases while blood loss of 1-2 litres occurs in 0.6% of women in labour.(1) A Uterine Balloon Device is inserted and inflated with 300-500ml saline (2) to apply pressure to the uterine wall to reduce bleeding. This simple, lifesaving improvisation was developed by Kenyan midwife using a large syringe, #24 catheter, a condom and string and has been used to good effect (2,3)
1. Royal College of Obstetricians and Gynaecologists (2013) "Information for you Heavy bleeding after birth (postpartum haemorrhage)".
2. Burke TF et al ( 2016) "A postpartum haemorrhage package with condom uterine balloon tamponade: a prospective multi-centre case series in Kenya, Sierra Leone, Senegal, and Nepal". British Journal of Obstetrics and Gynaecology. 123 (9) :1532-40
3. Pendleton AA et al (2016) "A qualitative assessment of the impact of a uterine balloon tamponade package on decisions regarding the role of emergency hysterectomy in women with uncontrolled postpartum haemorrhage in Kenya and Senegal". British Medical Journal. Open 2016;6:e010083. doi:10.1136/bmjopen-2015- 010083