Emergency.vnmu.edu.ua
Theme 4. Injuries. First aid in case of wound, fracture, luxation, sprain.
Questions
1. General information. Causes and signs of wounds of the soft tissues. Penetrating and blunt wounds of a skull, chest, abdomen.
2. Wound protection: bandaging. Bandaging in case of head, eye, ear, jaw injuries. Bandaging with foreign body embedded in the wound.
3. Chest injuries. First aid.
4. Abdominal injuries. Peculiarities in bandaging of penetrating abdominal injuries.
5. Causes and signs of head, spine, pelvic injuries.
6. Types of limbs’ injuries: fractures, sprains, luxation (dislocations).
7. Fractures (open, closed). Causes and signs. Absolute signs of fractures. First aid in case of open fractures.
8. Transport immobilization with improvised and manufactured means.
9. First aid for the road traffic accident. Rescuer’s tactics.
1. General information. Causes and signs of wounds of the soft tissues. Penetrating and blunt wounds of a head, chest, abdomen.
A wound is a break in the continuity of a tissue either external or internal. Wounds can be classified into two main types.
•Closed (internal)
•Open (external)
- Penetrating injury (head, chest, abdomen)
o with the damage of inner organs
o without damage of inner organs
o with damage of large vessels
o without damage of large vessels
- blunt injury
Any open injury can be penetrating the body, or non-penetrating. Penetrating injury appears when enters body’s cavity (skull, chest, abdomen. pelvis).
Open wounds
- Incisions-caused by a clean, sharp-edged object such as a knife, a razor or a glass splinter.
- Lacerations-rough, irregular wounds caused by crushing or ripping forces.
- Abrasions (grazes)-a superficial wound in which the top most layers of the skin are scraped off, often caused by a sliding fall onto a rough surface.
-Puncture wounds-caused by an object puncturing the skin, such as a nail or needle.
-Penetration wounds- an injury caused by an object breaking the skin and entering the body.
-Avulsion wounds–this is a wound that occurs due to the integrity of any tissue is compromised.
Closed wounds
-Contusions (bruise) -caused by blunt force trauma that damages tissues under the skin
-Hematoma-caused by damage to a blood vessel that in turn causes blood to collect under the skin
-Crushing injuries-caused by a great or extreme amount of force applied over a long period of time.
Signs & Symptoms
The general symptoms of a wound are localized pain and bleeding.
Also, you may find swelling, discoloration, hematoma, uncontrolled restlessness, thirst, shock, vomiting.
Specific symptoms include:
-A cut may have little or profuse bleeding depending on its depth and length; its even edges readily line up.
-A laceration too may have little or profuse bleeding; the tissue damage is generally greater and the wound's ragged edges do not readily line up.
-An abrasion usually appears as lines of scraped skin with tiny spots of bleeding.
-A puncture wound will be greater than its length, therefore there is usually little bleeding around the outside of the wound and more bleeding inside, causing discoloration.
-An avulsion has heavy, rapid bleeding and a noticeable absence of tissue.
-A contusion may appear as a bruise beneath the skin or may appear only on imaging tests; an internal wound may also generate symptoms such as weakness, perspiration, and pain.
-A crush wound may have irregular margins like a laceration; however, the wound will be deeper and trauma to muscle and bone may be apparent.
General ways to treat a wound.
Assessment
1. A quick, but thorough, assessment of the patient and the injury must be done initially.
2. Note the injury site, cause of injury, and degree of injury.
3. It is important to assess the life-threatening potential of the injury, and observe for signs of shock (paleness, rapid and shallow respirations, thirst, nausea and vomiting, weak and rapid pulse, restlessness, excitement and anxiety).
4. Fainting is not uncommon for the injured person during the assessment due to the loss of blood, deformity and pain.
5. It is best to have the individual lie down to prevent a possible fall and further injury.
In evaluating the casualty for location, type, and size of the wound or injury, cut or tear his clothing and carefully expose the entire area of the wound. This procedure is necessary to properly visualize injury and avoid further contamination. Clothing stuck to the wound should be left in place to avoid further injury. DO NOT touch the wound; keep it as clean as possible.
First aid for the closed wound is acronym for RICE:
- Rest the affected area
- Ice application or cold compress
- Compression over the affected area
- Elevate the affected area above the heart
The following are the 5 basic steps for treating an open wound:
1. Stop the bleeding. Put a clean cloth over the wound. Press down for at least 3 minutes.
2. Wash the wound. Washing the wound is the best way to prevent infection. Wash hands first with soap and water and rinse in purified water or sanitized solution. Wash wound with purified water and disinfectant soap.
3. Remove dirt particles. Lift flaps of skin gently with sterile tweezers. (Sterilize tweezers by boiling them in water for a few minutes or soaking in alcohol for 15 minutes and them covering them until they will be used.) Continue to squirt or pour purified water on the wound until it is completely clean.
4. Close the skin. A wound less than 12 hours old will heal faster with the edges held together. This can be done by stitches by a health worker or with a butterfly bandage made from adhesive tape.
5. Dress and cover the wound. Once the wound is clean and closed, it will heal faster.
Anytime a person is seriously hurt, for example with a cut or burn, they may react by going into shock.
Steps to follow if the person is in shock(just to remind):
-Have there person lie down with feet elevated above the heart.
-Cover person with a blanket.
-If person is conscious, let him drink warm liquids, especially oral rehydration solution.
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2. Wound protection: bandaging. Bandaging in case of head, eye, ear, jaw injuries. Bandaging with foreign body embedded in the wound.
Wounds can be protected with a help of dressings and bandages.
Dressing (medical) is a medical covering for a wound, usually made of cloth. A bandage is a piece of material used either to support a medical device such as a dressing or splint, or on its own to provide support to or to restrict the movement of a part of the body.
They have three key uses: applying pressure to bleeding wounds; covering wounds and burns; and providing support and immobilization for broken bones, sprains, and strains. These includes gauze, triangular, elastic, and tubular bandage.
To dress a wound, use a sterile low-adherent pad, which will not stick to the wound, but will absorb the blood coming from it. Once this is in place, wrap a crepe or conforming bandage around firmly. It should be tight enough to apply some direct pressure, but should not be so tight as to cut blood flow off below the bandage. A simple check for the bandage being too tight on a limb wound is a capillary refill check; to do this, hold the hand or foot (dependent on what limb is injured) above the level of the heart and firmly pinch the nail. If it takes more than 2 seconds for the pink color to return under the nail, then the bandage is likely to be too tight.
If the blood starts to come through the dressing you have applied, add another on top, to a maximum of three. If these are all saturated, remove the top two, leaving the closest dressing to the wound in place. This ensures that any blood clots that have formed are not disturbed; otherwise, the wound would be opened anew.
Head Wounds.
(1) Position the casualty.
WARNING: DO NOT move the casualty if you suspect he has sustained a neck, spine, or head injury (which produces any signs or symptoms other than minor bleeding).
• If the casualty has a minor (superficial) scalp wound and is conscious:
• Have the casualty sit up (unless other injuries prohibit or he is unable to).
• If the casualty is lying down and is not accumulating fluids or drainage in his throat, elevate his head slightly.
• If the casualty is bleeding from or into his mouth or throat, turn his head to the side or position him on his side so that the airway will be clear. Avoid putting pressure on the wound and place him on his uninjured side (Figure 3-1).
[pic]
• If the casualty is unconscious or has a severe head injury, then suspect and treat him as having a potential neck or spinal injury, immobilize and DO NOT move the casualty.
NOTE
If the casualty is choking or vomiting or is bleeding from or into his mouth (thus compromising his airway), position him on his uninjured side to allow for drainage and to help keep his airway clear.
WARNING: If it is necessary to turn a casualty with a suspected neck/spine injury; roll the casualty gently onto his side, keeping the head, neck, and body aligned while providing support for the head and neck. DO NOT roll the casualty by yourself but seek assistance. Move him only if absolutely necessary, otherwise keep the casualty immobilized to prevent further damage to the neck/spine.
(2) Expose the wound.
WARNING: DO NOT attempt to clean the wound or remove a protruding object.
(3) Apply a dressing to a wound of the forehead or back of head.
To apply a dressing to a wound of the forehead or back of the head—
(a) Remove the dressing from the wrapper.
(b) Grasp the tails of the dressing in both hands.
(c) Hold the dressing (white side down) directly over the wound.
DO NOT touch the white (sterile) side of the dressing or allow anything except the wound to come in contact with it.
(d) Place it directly over the wound.
(e) Hold it in place with one hand. If the casualty is able, he may assist.
(f) Wrap the first tail horizontally around the head; ensure the tail covers the dressing (Figure 3-2).
(g) Hold the first tail in place and wrap the second tail in the opposite direction, covering the dressing (Figure 3-3).
Figure 3-3. Second tail wrapped in opposite direction.
(h) Tie a square knot and secure the tails at the side of the head, making sure they DO NOT cover the eyes or ears (Figure 3-4).
Figure 3-4. Tails tied in square knot at side of head.
(4) Apply a dressing to a wound on top of the head. To apply a dressing to a wound on top of the head—
(a) Remove the dressing from the wrapper.
(b) Grasp the tails of the dressing in both hands.
(c) Hold it (white side down) directly over the wound.
DO NOT touch the white (sterile) side of the dressing or allow anything except the wound to come in contact with it.
(d) Place it over the wound (Figure 3-19).
(e) Hold it in place with one hand. If the casualty is able, he may assist.
(f) Wrap one tail down under the chin (Figure 3-6), up in front of the ear, over the dressing, and in front of the other ear.
WARNING: Ensure the tails remain wide and close to the front of the chin to avoid choking the casualty.
(g) Wrap the remaining tail under the chin in the opposite direction and up the side of the face to meet the first tail (Figure 3-7).
(h) Cross the tails (Figure 3-8), bringing one around the forehead (above the eyebrows) and the other around the back of the head (at the base of the skull) to a point just above and in front of the opposite ear, and tie them using a square knot.
(5) Apply a triangular bandage to the head. To apply a triangular bandage to the head—
(a) Turn the base (longest side) of the bandage up and center its base on the center of the forehead, letting the point (apex) fall on the back of the neck (Figure 3-10A).
(b) Take the ends behind the head and cross the ends over the apex.
(c) Take them over the forehead and tie them (Figure 3-10B).
(d) Tuck the apex behind the crossed part of the bandage or secure it with a safety pin, if available (Figure 3-10C).
[pic]
(6) Apply a cravat bandage to the head. To apply a cravat bandage to the head—
(a) Place the middle of the bandage over the dressing (Figure 3-11A).
(b) Cross the two ends of the bandage in opposite directions completely around the head (Figure 3-11B).
(c) Tie the ends over the dressing (Figure 3-11C).
Figure 3-11. Cravat bandage applied to head (Illustrated A—C).
[pic]
Eye Injuries.
The eye is a vital sensory organ, and blindness is a severe physical handicap. Timely first aid of the eye may relieve pain and may also help to prevent shock, permanent eye injury, and possible loss of vision. Because the eye is very sensitive, any injury can be easily aggravated if it is improperly handled. Injuries of the eye may be quite severe. Cuts of the eyelids can appear to be very serious, but if the eyeball is not involved, a person’s vision usually will not be damaged. However, lacerations (cuts) of the eyeball can cause permanent damage or loss of sight.
(1) Lacerated/torn eyelids. Lacerated eyelids may bleed heavily, but bleeding usually stops quickly. Cover the injured eye with a sterile dressing. DO NOT put pressure on the wound because you may injure the eyeball. Handle torn eyelids very carefully to prevent further injury. Place any detached pieces of the eyelid on a clean bandage or
dressing and immediately send them with the casualty to the medical facility.
(2) Lacerated eyeball (injury to the globe). Lacerations or cuts to the eyeball may cause serious and permanent eye damage. Cover the injury with a loose sterile dressing. DO NOT put pressure on the eyeball because additional damage may occur. An important point to remember is that when one eyeball is injured, you should immobilize both eyes. This is done by applying a bandage to both eyes. Because the eyes move together, covering both will lessen the chances of further damage to the injured eye. (However, in hazardous surroundings, leave uninjured eye uncovered to enable casualty to see.)
CAUTION
DO NOT apply pressure when there is a possible laceration of the eyeball. The eyeball contains fluid. Pressure applied over the eye will force the fluid out, resulting in permanent injury. APPLY PROTECTIVE DRESSING WITHOUT ADDED PRESSURE.
(3) Extruded eyeballs. Service members may encounter casualties with severe eye injuries that include an extruded eyeball (eyeball out-of-socket). In such instances you should gently cover the extruded eye with a loose moistened dressing and also cover the unaffected eye. DO NOT bind or exert pressure on the injured eye while applying the dressing. Keep the casualty quiet, place him on his back, treat for shock, and evacuate him immediately.
Cravat Bandage for the Eye
•Lay center of the first cravat over top of he with the front end falling over uninjured eye.
•Bring second cravat around head, over eyes, and over loose ends of first cravat. Tie in front
•Bring ends of first cravat back over top of head, tying there and pulling second cravat up and away form uninjured eye.
Ear Injuries.
Lacerated (cut) or avulsed (torn) ear tissue may not, in itself, be a serious injury. Bleeding, or the drainage of fluids from the ear canal, however, may be a sign of a head injury, such as a skull fracture.
DO NOT attempt to stop the flow from the inner ear canal nor put anything into the ear canal to block it. Instead, you should cover the ear lightly with a dressing. For minor cuts or wounds to the external ear, apply a cravat bandage as follows:
(1) Place the middle of the bandage over the ear (Figure 3-19A).
(2) Cross the ends, wrap them in opposite directions around the head, and tie them (Figures 3-19B and 3-19C).
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(3) If possible, place some dressing material between the back of the ear and the side of the head to avoid crushing the ear against the head with the bandage.
Jaw Injuries.
Before applying a bandage to a casualty’s jaw, remove all loose or free-floating foreign material from the casualty’s mouth.
If the casualty is unconscious, check for obstructions in the airway and remove if possible. If there is profuse bleeding in the oral cavity, the cavity may require loose packing with soft bandaging material prior to applying a bandage. Care should be taken to avoid occluding the airway. When applying the bandage, allow the jaw enough freedom to permit passage of air and drainage from the mouth.
(1) Apply bandages attached to field first aid dressing to the jaw. After dressing the wound, apply the bandages using the same technique illustrated in Figure 3-20A—C.
NOTE
The dressing and bandaging procedure outlined for the jaw serves a twofold purpose. In addition to stopping the bleeding and protecting the wound, it also immobilizes a fractured jaw.
(2) Apply a cravat bandage to the jaw.
(a) Place the bandage under the chin and pull its ends
upward. Adjust the bandage to make one end longer than the other (Figure 3-20A).
(b) Take the longer end over the top of the head to meet the short end at the temple and cross the ends over (Figure 3-20B).
(c) Take the ends in opposite directions to the other side of the head and tie them over the part of the bandage that was applied first (Figure 3-20C).
[pic]
The cravat bandage technique is used to immobilize a fractured jaw or to maintain a sterile dressing that does not have tail bandages attached.
If a foreign body is embedded in the wound
If there is something embedded in the wound, do not remove it.
Instead, apply pressure around the object using sterile gauze. Rolled bandages are perfect for this. Be careful not to disturb the object, as moving it may exacerbate the bleeding. This doesn't apply to superficial splinters and such. A useful rule of thumb: if it's causing bleeding, don't remove it. If it isn't, feel free. Apply pressure and secure with bandages then get medical aid.
• DO NOT remove it but apply padding on either side of the object and build it up to avoid pressure on the foreign body.
• Hold the padding firmly in place with a roller bandage or folded triangular bandage applied in a criss-cross method to avoid pressure on the object.
DO NOT remove the foreign object, but apply padding on either side.
4. Keep the patient at total rest
• Even if the injury involves the arm or upper part of the body, the patient should rest in a position of greatest comfort for at least 10 minutes to help control the bleeding.
5. Seek medical assistance
• If the wound appears to be minor and the patient is able to travel by car, arrange an urgent appointment with a local doctor to assess and treat the injury.
While waiting for an ambulance to arrive, observe the patient closely for any change in condition.
Severe bleeding
• Put on sterile disposable gloves and a face shield if available.
• Calm and reassure the person.
• Lay the person down.
• Apply firm, direct pressure using a clean pad (or sterile dressing if available) over the wound. The person's own hand can be used to apply pressure whilst getting a suitable dressing/putting on your gloves.
• Whilst applying the direct pressure, elevate and support the injured area above the level of the heart.
• Firmly wrap a bandage around the pad or dressing to hold it in place, but not so firmly that it cuts off the circulation extremities.
• If blood soaks through the pad and bandage, do not remove but cover with another pad and bandage, continuing to apply pressure to the wound until bleeding is controlled.
• Monitor for symptoms of shock: pale, cold or clammy skin; rapid breathing; rapid or weak pulse; reduced level of consciousness.
• If symptoms of shock are present:
• With the person lying down, raise and support their legs above the level of their heart (continue to keep the injured part elevated as well).
• Loosen any tight clothing around their neck or their waist.
• Keep the person warm.
3. Chest injuries. Flail chest. Pneumothorax. First aid.
Chest Wounds
Blunt trauma, bullet or missile wounds, stab wounds, or falls may cause chest injuries. These injuries can be serious and may cause death quickly if first aid is not administered in a timely manner. A casualty with a chest injury may complain of pain in the chest or shoulder area; he may have difficulty breathing.
His chest may not rise normally when he breathes. The injury may cause the casualty to cough up blood and to have a rapid or a weak heartbeat. A casualty with an open chest wound has a punctured chest wall. The sucking sound heard when he breathes is caused by air leaking into his chest cavity. This particular type of wound is dangerous and will collapse the injured lung. Breathing becomes difficult for the casualty because the wound is open. The service members life may depend upon how quickly you apply an occlusive dressing over the wound.
Chest injuries can be divided into closed and open ones.
Closed chest wounds
Chest wounds can be inherently serious as this area of the body protects the majority of the vital organs. Most chest trauma should receive professional medical attention, so consider calling for an ambulance for any serious chest injury.
The most likely injuries that can be caused with a chest injury include broken ribs. A single broken rib can be very painful for the patient, and a rib fracture carries with it the risk of causing internal injury, such as puncturing the lung, which can lead in turn to the lung collapsing.
There are also some specific, more complicated, rib fracture patterns, which include:
Flail chest – 2 or more rib fractures along the same rib(s)
Can cause a 'floating' segment of the chest wall which makes breathing difficult
Stove chest – all ribs fractured
Can cause the entire ribcage to lose its rigidity, causing great difficulty breathing
Recognition
• Trouble breathing
• Shallow breathing
• Tenderness at site of injury
• Deformity & bruising of chest
• Uneven expansion of chest
• Pain upon movement/deep breathing/coughing
• Cyanosis
• May cough up blood
• Crackling sensation in skin if lung is punctured
General Treatment Algorithm
• Assess ABCs and intervene as necessary
• Call for an ambulance
• Assist the victim into a position of comfort
• Conduct a secondary survey
• Monitor vitals carefully
Open chest wounds
An open pneumothorax or sucking chest wound - the chest wall has been penetrated (by knife, bullet, falling onto a sharp object...)
Recognition
• An open chest wound – escaping air
• Entrance and possible exit wound (exit wounds are more severe)
• Trouble breathing
• Sucking sound as air passes through opening in chest wall
• Blood or blood-stained bubbles may be expelled with each exhalation
• Coughing up blood
General Treatment Algorithm
• Assess ABCs and intervene as necessary
• Do not remove any embedded objects
• Call for an ambulance
• Flutter valve over wound, as described below
• Lateral positioning: victim's injured side down
• Treat for shock
• Conduct a secondary survey
• Monitor vitals carefully
First Aid for chest wounds
a. Evaluate the Casualty. Be prepared to perform first aid measures: clearing the airway, rescue breathing, treatment for shock, and/or bleeding control.
b. Expose the Wound. If appropriate, cut or remove the casualty’s clothing to expose the wound. Remember, DO NOT remove clothing that is stuck to the wound because additional injury may result. DO NOT attempt to clean the wound.
NOTE
Examine the casualty to see if there is an entry and exit wound.
If there are two wounds (entry, exit), perform the same procedure for both wounds. Treat the more serious (heavier bleeding, larger) wound first. It may be necessary to improvise a dressing for the second wound by using strips of cloth, such as a torn T-shirt, or whatever material is available. Also, listen for sucking sounds to determine if the chest wall is punctured.
c. Open the Field Dressing Plastic Wrapper. In cases where there is a sucking chest wound, the plastic wrapper is used with the field dressing to create an occlusive dressing. If a plastic wrapper is not available, or if an additional wound needs to be treated; cellophane, foil, or similar material may be used. The covering should be wide enough to extend 2 inches or more beyond the edges of the wound in all directions.
(1) Tear open one end of the casualty’s plastic wrapper covering the field dressing. Be careful not to destroy the wrapper and DO NOT touch the inside of the wrapper.
(2) Remove the inner packet (field dressing).
(3) Complete tearing open the empty plastic wrapper using as much of the wrapper as possible to create a flat surface.
. Place the Wrapper Over the Wound. Place the inside surface of the plastic wrapper directly over the wound when the casualty exhales and hold it in place. The casualty may hold the plastic wrapper in place if he is able.
e. Apply the Dressing to the Wound.
(1) Use your free hand and shake open the field dressing.
(2) Place the white side of the dressing on the plastic wrapper covering the wound.
(3) Have the casualty breathe normally.
(4) While maintaining pressure on the dressing, grasp one tail of the field dressing with the other hand and wrap it around the casualty’s back. If tape is available, tape three sides of the plastic wrapper to the chest wall to provide occlusive type dressing. Leave one side untapped to provide emergency escape for air that may build up in the chest. If tape is not available, secure wrapper on three sides with field dressing leaving the fourth side as a flap.
(5) Wrap the other tail in the opposite direction, bringing both tails over the dressing.
(6) Tie the tails into a square knot in the center of the dressing after the casualty exhales and before he inhales. This will aid in maintaining pressure on the bandage after it has been tied. Tie the dressing firmly enough to secure the dressing without interfering with the casualty’s breathing.
NOTE
When practical, apply direct manual pressure over the dressing for 5 to 10 minutes to help control the bleeding.
f. Position the Casualty. Position the casualty on his injured side or in a sitting position, whichever makes breathing easier (Figure 3-7).
[pic]
Figure 3-7. Casualty positioned (lying) on injured side.
g. Seek Medical Assistance. Contact medical personnel.
WARNING
If an occlusive dressing has been improperly placed, air may enter the chest cavity with no means of escape. This causes a life-threatening condition called tension pneumothorax. If the casualty’s condition (for example, difficulty breathing, shortness of breath, restlessness, or blueness/grayness of the skin) worsens after placing the dressing, quickly lift or remove, and then replace the occlusive dressing.
Tension pneumothorax
Tension pneumothorax is the progressive build-up of air within the pleural space, usually due to a lung or chest wall laceration which allows air to escape into the pleural space but not to return. Positive pressure ventilation may exacerbate this 'one-way-valve' effect. Progressive build-up of pressure in the pleural space pushes the mediastinum to the opposite hemithorax, and obstructs venous return to the heart. This leads to circulatory instability and may result in traumatic arrest.
Classic signs
The classic signs of a tension pneumothorax are deviation of the trachea away from the side with the tension, a hyper-expanded chest, an increased percussion note and a hyper-expanded chest that moves little with respiration.
|Trachea |[pic|
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|Expansion |[pic|
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|Percussion Note |[pic|
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|Breath sounds |[pic|
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|Neck veins |[pic|
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However these classic signs are usually absent and more commonly the patient is tachycardic and tachypnoeic, and may be hypoxic. These signs are followed by circulatory collapse with hypotension and subsequent traumatic arrest with pulseless electrical activity (PEA). Breath sounds and percussion note may be very difficult to appreciate and misleading in the trauma room.
Management: Needle Thoracostomy
Classical management of tension pneumothorax is emergent chest decompression with needle thoracostomy. A 14-16G intravenous cannula is inserted into the second rib space in the mid-clavicular line. The needle is advanced until air can be aspirated into a syringe connected to the needle. The needle is withdrawn and the cannula is left open to air. An immediate rush of air out of the chest indicates the presence of a tension pneumothorax. The manoeuver essentially converts a tension pneumothorax into a simple pneumothorax.
4. Abdominal injuries. Peculiarities in bandaging of penetrating abdominal injuries.
The abdomen can be injured in many ways. The abdomen alone may be injured or injuries elsewhere in the body may also occur. Injuries can be relatively mild or very severe.
Abdominal injuries are classified by the type of structure that is damaged and how the injury occurred. The types of structures include the
• Abdominal wall
• Solid organs (that is, the liver, spleen, pancreas, or kidneys)
• Hollow organs (that is, the stomach, small intestine, colon, ureters, or bladder)
• Blood vessels
Abdominal injuries may also be classified by whether the injury is
• Blunt
• Penetrating
Blunt trauma may involve a direct blow (for example, a kick), impact with an object (for example, a fall onto bicycle handlebars), or a sudden decrease in speed (for example, a fall from a height or a motor vehicle crash). The spleen and liver are the two most commonly injured organs. Hollow organs are less likely to be injured.
Penetrating injuries occur when an object breaks the skin (for example, as a result of a gunshot or a stabbing). Some penetrating injuries involve only the fat and muscles under the skin. These penetrating injuries are much less concerning than those that enter the abdominal cavity. Gunshots that enter the abdominal cavity almost always cause significant damage. However, stab wounds that enter the abdominal cavity do not always damage organs or blood vessels. Sometimes, a penetrating injury involves both the chest and the upper part of the abdomen. For example a downward stab wound to the lower chest may go through the diaphragm into the stomach, spleen, or liver.
Blunt or penetrating injuries may cut or rupture abdominal organs and/or blood vessels. Blunt injury may cause blood to collect inside the structure of a solid organ (for example the liver) or in the wall of a hollow organ (such as the small intestine). Such collections of blood are called hematomas. Uncontained bleeding into the abdominal cavity, in the space surrounding the organs, is called hemoperitoneum.
Cuts and tears begin bleeding immediately. Bleeding may be minimal and cause few problems. More serious injuries may cause massive bleeding with shock and sometimes death. Bleeding from abdominal injury is mostly internal (within the abdominal cavity). When there is a penetrating injury, a small amount of external bleeding may occur through the wound.
When a hollow organ is injured, the contents of the organ (for example, stomach acid, stool, or urine) may enter the abdominal cavity and cause irritation and inflammation (peritonitis).
Main signs are abdominal pain, tenderness, may be bruises on the abdominal wall due to blunt injury, swollen abdomen, hematomas. Signs of internal bleeding and shock.
In general - if a trauma injury has caused the victim's internal organs to protrude outside the abdominal wall, do not push them back in. Instead, have the person lie flat with their knees bent and cover the organs with a moist, sterile dressing (not paper products - use gauze). Do not allow the victim to eat or drink, though they may complain of extreme thirst. Call an ambulance treat for shock and monitor ABCs until the emergency medical team arrives.
If the abdominal injury does not cause an open wound, have the person lie flat with their knees bent and treat for shock until EMS arrives.
Step-by-step first aid for abdominal wounds
a. Evaluate the Casualty. Be prepared to perform basic first aid measures. Always check for both entry and exit wounds. If there are two wounds (entry and exit), treat the wound that appears more serious first (for example, the heavier bleeding, protruding organs, larger wound, and so forth). It may be necessary to improvise dressings for the second wound by using strips of cloth, a T-shirt, or the cleanest material available.
b. Position the Casualty. Place and maintain the casualty on his back with his knees in an upright (flexed) position (Figure 3-8). The knees up position helps relieve pain, assists in the treatment of shock, prevents further exposure of the bowel (intestines) or abdominal organs, and helps relieve abdominal pressure by allowing the abdominal muscles to relax.
Figure 3-8. Casualty positioned (lying) on back with knees (flexed) up.
c. Expose the Wound.
(1) Remove the casualty’s loose clothing to expose the wound.
However, DO NOT attempt to remove clothing that is stuck to the wound; removing it may cause further injury.
(2) Gently pick up any organs that may be on the ground. Do this with a clean, dry dressing or with the cleanest available material. Place the organs on top of the casualty’s abdomen.
DO NOT probe, clean, or try to remove any foreign object from the abdomen. DO NOT touch with bare hands any
exposed organs. DO NOT push organs back inside the body.
d. Apply the Field Dressing. Use the field dressing. If the field dressing is not large enough to cover the entire wound, the plastic wrapper from the dressing may be used to cover the wound first (placing the field dressing on top). Open the plastic wrapper carefully without touching the inner surface. If necessary, other improvised dressings may be made from clothing, blankets, or the cleanest materials available.
WARNING: If there is an object extending from the wound, DO NOT remove it. Place as much of the wrapper over the wound as possible without dislodging or moving the object. DO NOT place the wrapper over the object.
(1) Grasp the tails in both hands.
(2) Hold the dressing with the white side down directly over the wound. DO NOT touch the white (sterile) side of the dressing or allow anything except the wound to come in contact with it.
(3) Pull the dressing open and place it directly over the wound. If the casualty is able, he may hold the dressing in place.
(4) Hold the dressing in place with one hand and use the other hand to wrap one of the tails around the body.
(5) Wrap the other tail in the opposite direction until the dressing is completely covered. Leave enough of the tail for a knot.
(6) Loosely tie the tails with a square knot at the casualty’s side
WARNING
When the dressing is applied, DO NOT put pressure on the wound or exposed internal parts, because pressure could cause further injury (vomiting, ruptured intestines, and so forth). Therefore, tie the dressing ties (tails) loosely at casualty’s side, not directly over the dressing.
(7) Tie the dressing firmly enough to prevent slipping without applying pressure to the wound site.
Field dressings can be covered with improvised reinforcement material (cravats, strips of torn T-shirt, or other cloth) for additional support and protection. Tie improvised bandage on the opposite side of the dressing ties firmly enough to prevent slipping but without applying additional pressure to the wound.
DO NOT give casualties with abdominal wounds food or water (moistening the lips is allowed).
e. Seek Medical Assistance. Notify medical personnel.
5.
6. Causes and signs of head, spine, pelvic injuries.
a. Head Injuries.
(1) Head injuries range from minor abrasions or cuts on the scalp to severe brain injuries that may result in unconsciousness and sometimes death. Head injuries are classified as open or closed wounds. An open wound is one that is visible, has a break in the skin, and usually has evidence of bleeding. A closed wound may be visible (such as a depression in the skull) or the first aid provider may not be able to see any apparent injury (such as internal bleeding). Some head injuries result in unconsciousness; however, a service member may have a serious head wound and still be conscious. Casualties with head and neck injuries should be treated as though they also have a spinal injury. The casualty should not be moved until the head and neck is stabilized unless he is in immediate danger (such as close to a burning vehicle).
(2) Prompt first aid measures should be initiated for casualties with suspected head and neck injuries. The conscious casualty may be able to provide information on the extent of his injuries. However, as a result of the head injury, he may be confused and unable to provide accurate information. The signs and symptoms a first aid provider might observe are—
• Nausea and vomiting.
• Convulsions or twitches.
• Slurred speech.
• Confusion and loss of memory. (Does he know who he is? Does he know where he is? Does he know what day it is?)
• Recent unconsciousness.
• Dizziness.
• Drowsiness.
• Blurred vision, unequal pupils, or bruising (black eyes).
• Paralysis (partial or full).
• Complaint of headache.
• Bleeding or other fluid discharge from the scalp, nose, or ears.
• Deformity of the head (depression or swelling).
• Staggering while walking.
b. Neck Injuries. Neck injuries may result in heavy bleeding. Apply pressure above and below the injury, but do not interfere with the breathing process, and attempt to control the bleeding. Apply a dressing.
Always evaluate the casualty for a possible neck fracture/spinal cord injury; if suspected, seek medical treatment immediately.
NOTE
Establish and maintain the airway in cases of facial or neck injuries. If a neck fracture or spinal cord injury is suspected, immobilize the injury and, if necessary, perform basic life support measures.
c. Facial Injuries. Soft tissue injuries of the face and scalp are common. Abrasions (scrapes) of the skin cause no serious problems.
Contusions (injury without a break in the skin) usually cause swelling. A contusion of the scalp looks and feels like a lump. Laceration (cut) and avulsion (torn away tissue) injuries are also common. Avulsions are frequently caused when a sharp blow separates the scalp from the skull beneath it. Because the face and scalp are richly supplied with blood vessels (arteries and veins), wounds of these areas usually bleed heavily.
General First Aid Measures
a. General Considerations. The casualty with a head injury (or suspected head injury) should be continually monitored for the development of conditions that may require basic lifesaving measures. After initiating first aid measures, request medical assistance and evacuation. If dedicated medical evacuation assets are not available, transport the casualty to an MTF as soon as the situation permits. The first aid provider should not attempt to remove a protruding object from the head or give the casualty anything to eat or drink. Further, the first aid provider should be prepared to—
• Clear the airway.
• Control bleeding (external).
• Administer first aid measures for shock.
• Keep the casualty warm.
• Protect the wound.
b. Unconscious Casualty. An unconscious casualty does not have control of all of his body’s functions and may choke on his tongue, blood, vomitus, or other substances.
(1) Breathing. The brain requires a constant supply of oxygen. A bluish (or in an individual with dark skin—grayish) color of skin around the lips and nail beds indicates that the casualty is not receiving enough oxygen. Immediate action must be taken to clear the airway, to position the casualty on his side, or to initiate rescue breathing.
(2) Bleeding. Bleeding from a head injury usually comes from blood vessels within the scalp. Bleeding can also develop inside the skull or within the brain. In most instances visible bleeding from the head can be controlled by application of the field first aid dressing.
CAUTION
DO NOT attempt to put unnecessary pressure on the wound or attempt to push any brain matter back into the head (skull). DO NOT apply a pressure dressing.
c. Concussion. If an individual receives a heavy blow to the head or face, he may suffer a brain concussion (an injury to the brain that involves a temporary loss of some or all of the brain’s ability to function). For example, the casualty may not breathe properly for a short period of time, or he may become confused and stagger when he attempts to walk. Symptoms of a concussion may only last for a short period of time. However, if a casualty is suspected of having suffered a concussion, he should be transported to an MTF as soon as conditions permit.
d. Convulsions. Convulsions (seizures/involuntary jerking) may occur even after a mild head injury. When a casualty is convulsing, protect him from hurting himself. Take the following measures:
(1) Ease him to the ground if he is standing or sitting.
(2) Support his head and neck.
(3) Maintain his airway.
(4) Protect him from further injury (such as hitting close-by objects).
NOTE
DO NOT forcefully hold the arms and legs if they are jerking because this can lead to broken bones. DO NOT force anything between the casualty’s teeth—especially if they are tightly clenched because this may obstruct the casualty’s airway. Maintain the casualty’s airway if necessary.
e. Brain Damage. In severe head injuries where brain tissue is protruding, leave the wound alone; carefully place a loose moistened dressing (moistened with sterile normal saline if available) and also a first aid dressing over the tissue to protect it from further contamination. DO NOT remove or disturb any foreign matter that may be in the wound. Position the casualty so that his head is higher than his body. Keep him warm and seek medical assistance immediately.
NOTE
If there is an object extending from the wound, DO NOT remove the object. Improvise bulky dressings from the cleanest material available and place this material around the protruding object for support, then apply the field dressing.
Victims with a head injury also require assessment for a potential spinal injury. Any mechanism of injury that can cause a head injury can also cause a spinal injury.
Spinal Injury
It is often impossible to be sure a casualty has a fractured spinal column. Be suspicious of any back injury, especially if the casualty has fallen or if his back has been sharply struck or bent. If a casualty has received such an injury and does not have feeling in his legs or cannot move them, you can be reasonably sure that he has a severe back injury, which should be managed as a fracture. Remember, that the possibility of a neck fracture or injury to the back should always be suspected, and it is often impossible to be sure if a casualty has a fractured spinal column. If the spine is fractured, bending it can cause the sharp bone fragments to bruise or cut the spinal cord and result in permanent paralysis or death. The spinal column must maintain normal spinal position at the lower back (lumbar region) to help remove pressure from the spinal cord.
Note: only an x-ray can conclusively determine if a spinal injury exists. If a spinal injury is suspected, the victim must be treated as though one does exist.
Signs and symptoms:
• Mental confusion (such as paranoia or euphoria)
• Dizziness
• Head, neck or back pain
• Paralysis
• Any fall where the head or neck has fallen more than 2 meters (just over head height on an average male)
• Cerebrospinal fluid in the nose or ears
• Resistance to moving the head
• Pupils which are not equal and reactive to light
• Head or back injury
• Priapism
Treatment
Life over limb: Immobilize the spine as best as you can, but Airway, Breathing and Circulation take priority.
Step-by-step management.
a. If the casualty is not to be transported until medical personnel arrive—
• Caution him not to move. Ask him if he is in pain or if he is unable to move any part of his body.
• Leave him in the position in which he is found. DO NOT move any part of his body, unless he is in imminent danger.
• If the casualty is lying face up, slip a blanket or other supporting material under the arch of his lower back to help support the spine in a normal position. Take care not to place so much bulky padding as to cause potential damage by causing undo pressure on the spine. If he is lying face down, DO NOT put anything under any part of his body.
b. If the casualty must be transported to a safe location before medical personnel arrive and if the casualty is in a—
• Face-up position, transport him by litter or use a firm substitute, such as a wide board or a door longer than his height. Loosely tie the casualty’s wrists together over his waistline, using a cravat or a strip of cloth. Tie his feet together to prevent the accidental dropping or shifting of his legs. Lay a folded blanket across the litter where the arch of his back is to be placed. Using a four-man team (Figure 4-29), place the casualty on the litter without bending his spinal column or his neck.
Figure 4-29. Placing face-up casualty with fractured back onto litter.
• The number two man positions himself at the casualty’s head. His responsibility is to provide manual in-line (neutral) stabilization of the head and neck. The number three, and four men position themselves on one side of the casualty; all kneel on one knee along the side of the casualty. The number one man positions himself to the opposite side of the casualty (or can be on the same side of number three and four). The numbers two, three, and four men gently place their hands under the casualty. The number one man on the opposite side places his hands under the injured part to assist.
• When all four men are in position to lift, the number two man commands, “PREPARE TO LIFT” and then, “LIFT.” All men, in unison, gently lift the casualty about 8 inches. Once the casualty is lifted, the number one man recovers and slides the litter under the casualty, ensuring that the blanket is in proper position. The number one man then returns to his original lift position (Figure 4-29).
• When the number two man commands, “LOWER CASUALTY,” all men, in unison, gently lower the casualty onto the litter.
• Facedown position, he must be transported in this same position. The four-man team lifts him onto a regular or improvised litter, keeping the spinal column in a normal spinal position. If a regular litter is used, first place a folded blanket on the litter at the point where the chest will be placed.
Otherwise, the victim should not be moved unless absolutely necessary. Without moving the victim, check if the victim is breathing. If they are not, CPR must be initiated; the victim must be rolled while attempting to minimize movement of the spine. If the victim is breathing, immobilize their spine in the position found. The easiest way to immobilize the spine in the position found is sandbagging. Despite the name, it doesn't necessarily require bags of sand. Simply pack towels, clothing, bags of sand etc. around the victim's head such that it is immobilized. Be sure to leave their face accessible, since you'll need to monitor their breathing.
If you must roll the victim over to begin CPR, take great care to keep their spine immobilized. You may want to recruit bystanders to help you. Hands-on training is the only way to learn the various techniques which are appropriate for use in this situation.
Technique: Immobilising the head with both hands
1 Kneel behind the casualty’s head. Hold the head in both hands, supporting your forearms on your thighs. Do this without moving the casualty’s head.
2 Stabilise the head until the emergency services arrive.
[pic]
Technique: Stabilising the head between the legs
1 Kneel behind the casualty’s head.
2 Place both knees as close as possible on either side of the casualty’s shoulders. Take care not to move the head.
Pelvic injury.
Pelvic fracture is a disruption of the bony structure of the pelvis, including the hip bone, sacrum and coccyx. The most common cause in elderly is a fall, but the most significant fractures involve high-energy forces such as a motor vehicle crashes, cycling accidents, or a fall from significant height. Because the pelvis cradles so many internal organs, pelvic fractures may produce significant internal bleeding which is invisible to the eye.
The bony pelvis consists of the ilium (i.e., iliac wings), ischium, and pubis, which form an anatomic ring with the sacrum. Disruption of this ring requires significant energy. When it comes to the stability and the structure of the pelvis, or pelvic girdle, understanding its function as support for the trunk and legs helps to recognize the effect a pelvic fracture has on someone. The pubic bone, the ischium and the ilium make up the pelvic girdle, fused together as one unit. They attach to both sides of the spine and circle around to create a ring and sockets to place hip joints. Attachment to the spine is important to direct force into the trunk from the legs as movement occurs, extending to one’s back. This requires the pelvis to be strong enough to withstand pressure and energy. Various muscles play important roles in pelvic stability. Because of the forces involved, pelvic fractures frequently involve injury to organs contained within the bony pelvis. In addition, trauma to extra-pelvic organs is common. Pelvic fractures are often associated with severe hemorrhage due to the extensive blood supply to the region.
Classification
Pelvic fractures are most commonly described using one of two classification systems. The different forces on the pelvis result in different fractures. Sometimes they are determined based on stability or instability.
The Tile classification System
The Tile classification system is based on the integrity of the posterior sacroiliac complex.
In type A injuries, the sacroiliac complex is intact. The pelvic ring has a stable fracture that can be managed non-operatively.
Type B injuries are caused by either external or internal rotational forces resulting in partial disruption of the posterior sacroiliac complex. These are often unstable.
Type C injuries are characterized by complete disruption of the posterior sacroiliac complex and are both rotationally and vertically unstable. These injuries are the result of great force, usually from a motor vehicle crash, fall from a height, or severe compression.
The Young-Burgess classification system
The Young-Burgess classification system is based on mechanism of injury: anteroposterior compression type I, II and III, lateral compression types I, II and III, and vertical shear, or a combination of forces.
Lateral compression (LC) fractures involve transverse fractures of the pubic rami, either ipsilateral or contralateral to a posterior injury.
• Grade I – Associated sacral compression on side of impact
• Grade II – Associated posterior iliac ("crescent") fracture on side of impact
• Grade III – Associated contralateral sacroiliac joint injury
The most common force type, lateral compression (LC) forces, from side-impact automobile accidents and pedestrian injuries, can result in an internal rotation. The superior and inferior pubic rami may fracture anteriorly, for example. Injuries from shear forces, like falls from above, can result in disruption of ligaments or bones. When multiple forces occur, it is called combined mechanical injury (CMI).
Open book fracture
One specific kind of pelvic fracture is known as an 'open book' fracture. This is often the result from a heavy impact to the groin (pubis), a common motorcycling accident injury. In this kind of injury, the left and right halves of the pelvis are separated at front and rear, the front opening more than the rear, i.e. like an open book that falls to the ground and splits in the middle. Depending on the severity, this may require surgical reconstruction before rehabilitation. Forces from an anterior or posterior direction, like head-on car accidents, usually cause external rotation of the hemipelvis, an “open-book” injury. Open fractures have increased risk of infection and hemorrhaging from vessel injury, leading to higher mortality.
Signs and symptoms.
Most patients with a pelvic fracture have groin and/or lower back pain. Compression of the pubic symphysis or simultaneous compression of both anterior superior iliac spines is usually painful, particularly in severe fractures, and may indicate instability. Depending on the severity of the fracture, patients may or may not be able to walk. Signs of genitourinary and/or gynecologic (usually vaginal) injuries include
• Blood at the urethral meatus
• Scrotal or perineal hematoma
• Hematuria
• Anuria
• A high-riding prostate
• Vaginal bleeding
Intestinal or rectal injuries can cause
• Abdominal or pelvic pain
• Rectal bleeding
• Later development of peritonitis
Neurologic injuries can cause
• Weakness or loss of sensation and reflexes in the lower extremities, rectum, or perineum
• Incontinence
• Urinary retention
Mortality rate is high when fractures are unstable or posterior or when they cause hemorrhagic shock.
Treatment
Emergency treatment consists of advanced trauma life support management. After stabilization, the pelvis may be surgically reconstructed.
• For stable fractures, usually only symptomatic treatment
• For unstable fractures, external fixation, or open reduction and internal fixation
• For significant hemorrhage, external fixation or sometimes angiographic embolization or pelvic packing
Stable fractures often require only symptomatic treatment, particularly when patients can walk unaided. Acetabular fractures result from a high-energy injury (eg, a fall from height or a motor vehicle crash). Acetabular fractures are treated surgically if the fractures are displaced or instability persists after closed reduction. Acetabular fractures with posterior wall injuries are managed nonsurgically.
Unstable fractures should be wrapped (eg, in sheets) or stabilized with a commercially available pelvic binder as soon as possible in the emergency department; such stabilization can often decrease or stop bleeding.
Orthopedic consultation is recommended for these injuries.
6. Types of limbs’ injuries: fractures, sprains, luxations.
Musculoskeletal injuries include
• Fractures
• Joint dislocations
• Ligament sprains
• Muscle strains
• Tendon injuries
These injuries are common and vary greatly in mechanism, severity, and treatment.
Musculoskeletal injuries may occur in isolation or as part of multisystem trauma Most musculoskeletal injuries result from blunt trauma, but penetrating trauma can also damage musculoskeletal structures.
Fractures and dislocations may be open (in communication with the environment via a skin wound) or closed.
Fractures
A fracture is a break in a bone. Most involve a single, significant force applied to normal bone.
In a closed fracture, the overlying skin is intact. In an open fracture, the overlying skin is disrupted and the broken bone is in communication with the environment.
Pathologic fractures occur when mild or minimal force fractures an area of bone weakened by a disorder (eg, osteoporosis, cancer, infection, bone cyst). When the disorder is osteoporosis, they are often called insufficiency or fragility fractures.
Stress fractures result from repetitive application of moderate force, as may occur in long-distance runners or in soldiers marching while carrying a heavy load. Normally, bone damaged by microtrauma from moderate force self-repairs during periods of rest, but repeated application of force to the same location predisposes to further injury and causes the microtrauma to propagate.
Dislocations
A dislocation is a complete separation of the 2 bones that form a joint. Subluxation is partial separation. Often, a dislocated joint remains dislocated until reduced (realigned) by a clinician, but sometimes it reduces spontaneously.
Sprains and strains
Ligaments connect one bone to another. Tears may occur in ligaments (sprains) or in muscles (strains).
Tears may be graded as
• 1st degree: Minimal (fibers are stretched but intact, or only a few fibers are torn)
• 2nd degree: Partial (some to almost all fibers are torn)
• 3rd degree: Complete (all fibers are torn)
Tendon injuries
Tendons connect muscles to bones. Tendon tears can also be partial or complete.
With complete tears, the motion produced by the detached muscle is usually lost.
Partial tears can result from a single traumatic event (eg, penetrating trauma) or repeated stress (chronically, causing tendinopathy). Motion is often intact, but partial tears may progress to complete tears, particularly when significant or repetitive force is applied.
Healing
Bone heals at various rates, depending on the patient's age and coexisting disorders. For example, children heal much faster than adults; disorders that impair peripheral circulation (eg, diabetes, peripheral vascular disease) slow healing.
Fractures heal in 3 overlapping stages:
• Inflammatory
• Reparative
• Remodeling
The inflammatory phase occurs first. A hematoma forms at the fracture site, and a small amount of bone in the distal fracture fragments is resorbed. If a fracture line is not evident initially (eg, in some nondisplaced fractures), one typically becomes evident about 1 wk after the injury as this small amount of bone is resorbed.
During the reparative phase, a callus is formed. New blood vessels develop, enabling cartilage to form across the fracture line. Immobilization (eg, casting) is needed during the first 2 stages to allow new blood vessels to grow. The reparative phase ends with clinical union of the fracture (ie, when there is no pain at fracture site, the injured extremity can be used without pain, and clinical examination detects no bone movement).
In the remodeling stage, the callus, which was originally cartilaginous, becomes ossified, and the bone is broken down and rebuilt (remodeled). During this stage, patients should be instructed to gradually resume moving the injured part normally, including putting load-bearing stress on it.
Most joint dislocations can be reduced (returned to the normal anatomic position) without surgery. Occasionally, dislocations cannot be reduced using closed manipulative techniques, and open surgery is required. Once a joint is reduced, additional surgery is often not necessary, However, surgery is sometimes required to manage associated fractures, debris in the joint, or residual instability.
Many partial tears to ligaments, tendons, or muscles heal spontaneously. Complete tears often require surgery to restore anatomy and function. Prognosis and treatment vary greatly depending on the location and severity of the injury.
Signs and symptoms.
Sprains, strains, dislocations, and fractures can all present with the same symptoms. It is very difficult to determine what the injury may be. It is not necessary to know which injury the victim has as the treatment will be the same for all of them.
If the patient has any of the following symptoms, you should treat for a possible muscle or skeletal injury.
• Deformity at the injury site
• Crepitus - A grinding or cracking sound when the affected area is moved (usually accompanied by extreme pain). (Do not test for this! It should be reported by the patient.)
• Bruising and swelling
• No pulse below injury site
• Inability to use the affected body part normally If the injury appears to be severe, EMS should be activated as soon as possible.
Treatment
The treatment for any muscle, bone or joint injury follows the simple acronym "RICE".
Rest - Rest is very important for soft tissue injuries, both in the short term and for longer term care.
Immobilize - Sprains, strains and dislocations can slinged; fractures should be splinted and slinged.
Cold - Ice should be applied periodically, for around 10-20 minutes at a time. You should then take the ice off for around the same time it was on for. In order to avoid problems, always place some fabric between the ice and the skin.
Elevation - Where appropriate, the injury should be elevated, as this may help reduce the localized swelling which occurs. Do not elevate if this causes more pain to the victim.
Complications
Serious complications are unusual but may threaten life or limb viability or cause permanent limb dysfunction. Risk of complications is high with open injuries (which predispose to infection) and with injuries that disrupt blood vessels, tissue perfusion, and/or nerves. Dislocations, particularly if not rapidly reduced, tend to have a higher risk of vascular and nerve injuries than do fractures. Closed injuries that do not involve blood vessels or nerves, particularly those that are quickly reduced, are least likely to result in serious complications.
Acute complications (associated injuries) include the following:
• Bleeding : Bleeding accompanies all fractures and soft-tissue injuries. Rarely, internal or external bleeding is severe enough to cause hemorrhagic shock.
• Vascular injuries : Some open fractures disrupt blood vessels. Some closed injuries, particularly knee or hip dislocations and posteriorly displaced supracondylar humeral fractures, disrupt the vascular supply sufficiently to cause distal limb ischemia.
• Nerve injuries: Nerves may be injured when stretched by displaced pieces of a fractured bone or by a dislocated joint, when bruised by a blunt blow, when crushed in a severe crush injury, or when torn by sharp bone fragments. When nerves are bruised (called neurapraxia), nerve conduction is blocked, but the nerve is not torn. Neurapraxia causes temporary motor and/or sensory deficits; neurologic function returns completely in about 6 to 8 wk. When nerves are crushed (called axonotmesis), the axon is injured, but the myelin sheath is not. This injury is more severe than neurapraxia. Depending on the extent of the damage, the nerve can regenerate over weeks to years. Usually, nerves are torn (called neurotmesis) in open injuries. Torn nerves do not heal spontaneously and may have to be repaired surgically.
• Fat embolism: Fractures of long bones may release fat (and other marrow contents) that embolizes to the lungs and causes respiratory complications.
• Compartment syndrome: Tissue pressure increases in a closed fascial space, disrupting the vascular supply and reducing tissue perfusion. Crush injuries or markedly comminuted fractures are a common cause, increasing tissue pressure as edema develops. Risk is high with forearm fractures that involve both the radius and ulna, tibial plateau fractures (proximal tibial fractures that extend into the joint space), or tibial shaft fractures. Untreated compartment syndrome can lead to rhabdomyolysis, hyperkalemia, and infection. It can also cause contractures, sensory deficits, and paralysis. Compartment syndrome threatens limb viability (possibly requiring amputation) and survival.
• Infection: Any injury can become infected, but risk is highest with those that are open or surgically treated. Acute infection can lead to osteomyelitis, which can be difficult to cure.
Long-term complications include the following:
• Instability: Various fractures, dislocations, and ligament injuries, particularly 3rd-degree sprains, can lead to joint instability.
• Stiffness and impaired range of motion: Fractures that extend into joints usually disrupt articular cartilage; misaligned articular cartilage tends to scar, causing osteoarthritis and impairing joint motion. Stiffness is more likely if a joint needs prolonged immobilization. The knee, elbow, and shoulder are particularly prone to posttraumatic stiffness, especially in the elderly.
• Nonunion or delayed union: Occasionally, fractures do not heal (called nonunion), or union is delayed. Major contributing factors include incomplete immobilization, partial disruption of the vascular supply, and patient factors that impair healing (eg, use of corticosteroids or thyroid hormone).
• Malunion: Malunion is healing with residual deformity. It is more likely if a fracture is not adequately reduced and stabilized.
• Osteonecrosis: Part of a fracture fragment can become necrotic, primarily when the vascular supply is damaged. Closed injuries prone to osteonecrosis include scaphoid fractures, displaced femoral neck fractures, dislocations of a native (not prosthetic) hip, and displaced talar neck fractures.
• Osteoarthritis: Injuries that disrupt the weight-bearing surfaces of joints or that result in joint malalignment and instability predispose to joint cartilage degeneration and osteoarthritis.
7. Fractures (open, closed). Causes and signs. Absolute signs of fractures. First aid in case of open fractures. Peculiarities.
A fracture is any break in the continuity of a bone. Fractures can cause total disability or in some cases death by severing vital organs and/or arteries. On the other hand, they can most often be treated so there is a complete recovery. The potential for recovery depends greatly upon the first aid the individual receives before he is moved. First aid includes immobilizing the fractured part in addition to applying lifesaving measures when necessary. The basic splinting principle is to immobilize the joints above and below the fracture.
Classification due to:
Mechanism
• Traumatic fracture - This is a fracture due to sustained trauma. e.g.- Fractures caused by a fall, road traffic accident, fight etc.
• Pathologic fracture - A fracture through a bone which has been made weak by some underlying disease is called pathological fracture. e.g.- a fracture through a bone weakened by metastasis. Osteoporosis is the most common cause of pathological fracture.
• Periprosthetic fracture - A fracture at the point of mechanical weakness at the end of an implant
Soft-tissue involvement
• Closed fracture: are those in which the overlying skin is intact
• Open fracture/Compound fracture: involve wounds that communicate with the fracture, or where fracture hematoma is exposed, and may thus expose bone to contamination. Open injuries carry a higher risk of infection.
▪ Clean fracture
▪ Contaminated fracture
Displacement
• Non-displaced
• Displaced
▪ Translated
▪ Angulated
▪ Rotated
▪ Shortened
Spatial relationship between fracture fragments:
|Distraction, displacement, angulation, or shortening (overriding) may occur. |
|Distraction is separation in the longitudinal axis. |
|Displacement is the degree to which the fractured ends are out of alignment with each other; it is described in millimeters or bone width |
|percentage. |
|Angulation is the angle of the distal fragment measured from the proximal fragment. |
|Displacement and angulation may occur in the ventral-dorsal plane, lateral-medial plane, or both. |
|[pic] |
Fracture pattern
• Linear fracture: A fracture that is parallel to the bone's long axis.
• Transverse fractures are perpendicular to the long axis of a bone.
• Oblique fractures occur at an angle.
• Spiral fractures result from a rotatory mechanism; on x-rays, they are differentiated from oblique fractures by a component parallel to the long axis of bone in at least 1 view.
• Comminuted fractures have > 2 bone fragments. Comminuted fractures include segmental fractures (2 separate breaks in a bone).
• Avulsion fractures are caused by a tendon dislodging a bone fragment.
• In impacted fractures, bone fragments are driven into each other, shortening the bone; these fractures may be visible as a focal abnormal density in trabeculae or irregularities in bone cortex.
• Torus fractures (buckling of the bone cortex) and greenstick fractures (cracks in only 1 side of the cortex) are childhood fractures.
[pic]
Fragments
• Incomplete fracture: A fracture in which the bone fragments are still partially joined. In such cases, there is a crack in the osseous tissue that does not completely traverse the width of the bone
• Complete fracture: A fracture in which bone fragments separate completely.
• Comminuted fracture: A fracture in which the bone has broken into several pieces.
Anatomical location
An anatomical classification may begin with specifying the involved body part, such as the head or arm, followed with more specific localization. Fractures that have additional definition criteria than merely localization can often be classified as subtypes of fractures that merely are, such as a Holstein-Lewis fracture being a subtype of a humerus fracture. However, most typical examples in an orthopedic classification given in previous section cannot appropriately be classified into any specific part of an anatomical classification, as they may apply to multiple anatomical fracture sites.
NOTE An open fracture is contaminated and subject to infection.
General Signs and Symptoms of Fractures
1. Pain at or near the seat of fracture.
2. Tenderness of discomfort on getle pressure over the affected area.
3. Swelling about the seat of fracture. Swelling frequently render it difficult to perceive other signs of fracture and care must be taken therefore not to treat the condition as a less serious injury.
4. Loss or power; the injured part cannot be moved normally
5. Deformity of the limb; the limb may assume an unnatural position and be mis-shapen.
The contracting muscles may cause the broken ends of the bone to override, thereby producing shortening of the limp.
6. Irregularity of the bone. If the fracture is near the skin the irregularity of the bone may be felt.
7. Crepitus (bony grating) may be heard or felt.
8. Unnatural movement at the seat of the fracture.
The last two signs should never be sought deliberately, but they may be noted during examination.
Any or all of these signs and symptoms may not be present: those which are may vary in degree.
Comparison with the uninjured side will assist in the diagnosis.
In addition to these signs and symptoms, marks on the clothing or skin may serve to locate the fracture. The snap of the bone may have been heard or felt.
WARNING: DO NOT encourage the casualty to move the injured part in order to identify a fracture since such movement could cause further damage to surrounding tissues and promote shock. If you are not sure whether a bone is fractured, care for the injury as a fracture. At the site of the fracture, the bone ends are sharp and could cause vessel (artery and/or vein) damage.
Treatment
• Treatment of associated injuries
• Reduction as indicated, splinting, and analgesia
• RICE (rest, ice, compression, and elevation) or PRICE (including protection) as indicated
• Usually immobilization
• Sometimes surgery
9. Transport immobilization with improvised and manufactured means.
A fracture is immobilized to prevent the sharp edges of the bone from moving and cutting tissue, muscle, blood vessels, and nerves. This reduces pain and helps prevent or control shock. In a closed fracture, immobilization keeps bone fragments from causing an open wound, which can become contaminated and subject to infection.
Splints, Padding, Bandages, Slings, and Swathes
a. Splints. Splints may be improvised from such items as boards, poles, sticks, tree limbs, or cardboard. If nothing is available for a splint, the chest wall can be used to immobilize a fractured arm and the uninjured leg can be used to immobilize (to some extent) the fractured leg.
b. Padding. Padding may be improvised from such items as a jacket, blanket, poncho, shelter half, or leafy vegetation.
c. Bandages. Bandages may be improvised from belts, slings, kerchiefs, or strips torn from clothing or blankets. Narrow materials such as wire or cord should not be used to secure a splint in place. The application of wire and/or narrow material to an extremity could cause tissue damage and a tourniquet effect.
d. Slings. A sling is a bandage suspended from the neck to support an upper extremity. If a bandage is not available, a sling can be improvised by using the tail of a coat or shirt or pieces of cloth torn from such items as clothing and blankets. The triangular bandage is ideal for this purpose. Remember that the casualty’s hand should be higher than his elbow, and the fingers should be showing at all times. The sling should be applied so that the supporting pressure is on the uninjured side.
e. Swathes. Swathes are any bands (pieces of cloth or load bearing equipment) that are used to further immobilize a splinted fracture. Triangular and cravat bandages are often used and are called swathe bandages. The purpose of the swathe is to immobilize; therefore, the swathe bandage is placed above and/or below the fracture—not over it.
Splinting Suspected Fractures
Before beginning first aid procedures for a fracture, gather whatever splinting materials are available. Ensure that splints are long enough to immobilize the joint above and below the suspected fracture. If possible, use at least four ties (two above and two below the fracture) to secure the splints. The ties should be square knots and should be tied away from the body on the splint. Distal pulses of the affected extremity should be checked before and after the application of the splint.
a. Evaluate the Casualty. Be prepared to perform any necessary lifesaving measures. Monitor the casualty for development of conditions that may require you to perform necessary lifesaving measures.
WARNING: Unless there is immediate life-threatening danger, such as a fire or an explosion, DO NOT move the casualty with a suspected back or neck injury. Improper movement may cause permanent paralysis or death.
b. Locate the Site of the Suspected Fracture.
(1) Ask the casualty for the location of the injury.
• Does he have any pain?
• Where is it tender?
• Can he move the extremity?
NOTE With the presence of an obvious deformity, do not make the casualty move extremity.
(2) Look for an unnatural position of the extremity.
(3) Look for a bone sticking out (protruding).
c. Prepare the Casualty for Splinting the Suspected Fracture.
(1) Reassure the casualty. Tell him that you will be providing first aid for him and that medical help is on the way.
(2) Loosen any tight or binding clothing.
(3) Remove all jewelry from the injured part and place it in the casualty’s pocket. Tell the casualty you are doing this because if the jewelry is not removed and swelling occurs later, he may not be able to get it off and further bodily injury could result.
(4) Boots should not be removed from the casualty unless they are needed to stabilize a neck injury or there is actual bleeding from the foot.
d. Gather Splinting Materials. If standard splinting materials (splints, padding, and cravats) are not available, gather improvised materials. If splinting material is not available and the suspected fracture CANNOT be splinted, then swathes, or a combination of swathes and slings can be used to immobilize the extremity.
e. Pad the Splints. Pad the splints where they touch any bony part of the body, such as the elbow, wrist, knee, ankle, crotch, or armpit areas. Padding prevents excessive pressure on the area, which could lead to circulation problems.
f. Check the Circulation Below the Site of the Injury.
(1) Note any pale, white, or bluish-gray color of the skin, which may indicate impaired circulation. Circulation can also be checked by depressing the toe or fingernail beds and observing how quickly the color returns. A slower return of color to the injured side when compared with the uninjured side indicates a problem with circulation. The fingernail bed is the method to use to check the circulation in a dark-skinned casualty.
(2) Check the temperature of the injured extremity. Use your hand to compare the temperature of the injured side with the uninjured side. The body area below the injury may be colder to the touch indicating poor circulation.
(3) Question the casualty about the presence of numbness, tightness, cold, or tingling sensations.
WARNING
Casualties with fractures of the extremities may show impaired circulation, such as numbness, tingling, cold or pale to bluish skin tone. These casualties should be evacuated by medical personnel and treated as soon as possible. Prompt medical treatment may prevent possible loss of the limb.
WARNING
If it is an open fracture and the bone is protruding from the skin, DO NOT ATTEMPT TO PUSH THE BONE BACK UNDER THE SKIN. Apply a field dressing over the wound to protect the area.
g. Apply the Splint in Place.
(1) Splint the fracture in the position found. DO NOT attempt to reposition or straighten the injury. If it is an open fracture, stop the bleeding and protect the wound. Cover all wounds with field dressings before applying a splint.
(2) Place one splint on each side of the fracture. Make sure that the splints reach, if possible, beyond the joints above and below the fracture.
(3) Tie the splints. Secure each splint in place above and below the fracture site with improvised (or actual) cravats. Improvised cravats, such as strips of cloth, belts, or whatever else you have, may be used. With minimal motion to the injured areas, place and tie the splints with the bandages. Push cravats through and under the natural body curvatures, and then gently position improvised cravats and tie in place. Use square knots. Tie all knots on the splint away from the casualty (Figure) DO NOT tie cravats directly over the suspected fracture site.
[pic]
Square knots tied away from casualty.
h. Check the Splint for Tightness.
(1) CHECK to be sure that bandages are tight enough to securely hold splinting materials in place, but not so tight that circulation is impaired.
(2) RECHECK the circulation after application of the splint. Check the skin color and temperature. This is to ensure that the bandages holding the splint in place have not been tied too tightly. A fingertip check can be made by inserting the tip of the finger between the bandaged knot and the skin.
(3) MAKE any necessary adjustment without allowing the splint to become ineffective.
i. Apply a Sling. An improvised sling may be made from any available non-stretching piece of cloth, shirt or trousers, poncho. Slings may also be improvised using the tail of a coat, belt, or a piece of cloth. Figure 4-3 depicts a shirttail used for support. A trousers belt may also be used for support (Figure 4-4). A sling should place the supporting pressure on the casualty’s uninjured side. The supported arm should have the hand positioned slightly
higher than the elbow showing the fingers.
[pic]
(1) Insert the splinted arm in the center of the sling.
(2) Bring the ends of the sling up and tie them at the side (or hollow) of the neck on the uninjured side.
(3) Twist and tuck the corner of the sling at the elbow.
j. Apply a Swathe. You may use any large piece of cloth, service member’s belt, or pistol belt, to improvise a swathe.
WARNING
The swathe should not be placed directly on top of the injury, but positioned either above or below the fracture site.
(1) Apply swathes to the injured arm by wrapping the swathe over the injured arm, around the casualty’s back, and under the arm on the uninjured side. Tie the ends on the uninjured side.
(2) A swathe is applied to an injured leg by wrapping the swathe around both legs and securing it on the uninjured side.
k. Seek Medical Assistance. Notify medical personnel, watch closely for development of life-threatening conditions and/or impaired circulation to the injured extremity.
MANAGEMENT OF SPECIFIC FRACTURES
Hand and fingers Bandage in a fist around a rolled-up sock and elevate in a sling (i.e. splint the hand in the position of function)
Forearm Splint the wrist straight and the elbow at 90º
Elbow/upper arm/ Use a broad arm sling with a swathe around the body shoulder to reduce movement
Collar bone Use a broad arm sling
Foot and toes Often well-splinted in a boot. Watch for numbness and swelling. It may be necessary to cut the boot off if swelling occurs
Ankles Immobilise the foot and knee. Assisted walking may be possible
Lower leg/knee Immobilise foot, ankle and knee
Thigh/hip Traction is desirable as the bone ends often override damaging the surrounding tissues. Splint both legs together or use a traction splint. In hip fractures there is characteristic shortening and external rotation on the affected side
Pelvis Treat as for a fractured thigh. Pelvic fractures are associated with severe bleeding and damage to internal organs. Suspect if pressure on the pelvis leads to pain. Bind the legs together to prevent further movement of pelvic fragments
[pic]
8. 9 First aid in traffic accident. Rescuer’s tactics in traffic accident.
Initial first aid consists of DR ABC DE and taking a SAMPLE history. These acronyms, if followed systematically can help you assess, diagnose and provide adequate first aid to treat the casualty. Keep in mind, that your care of the casualty could be more important and lifesaving, than you going off to call for help which may not arrive in time!!!
For any incident, there are basic rules to follow until you can get medical help. Use the principles of first aid assess the casualty. They are:
D Check for Danger
R Look for Response
A Airway with c-spine protection
B Breathing
C Circulation with control of bleeding
D Disability (neurological exam). On this stage it is possible to check for DOTS: D is for deformity. When you look at the casualty see if you see any abnormal posture or position of the limbs. O is for an open wound. The injury may have caused an open bleeding wound. T is for tenderness. When you examine the casualty as below, she may complain of pain. If unconscious, there may be a grimace or moan. S is for swelling. Injuries, fractures can cause a swelling in the area.
E Exposure with environment control
Important points to remember
· As you approach an incident consider the mechanism of injury and mentally consider the injuries that may be present.
· Introduce yourself to the sick or injured person and explain what you are doing.
· When you check her pockets or purse for ID or medication explain why you are doing this, else she could think you are trying to rob her!
· Always reassure the person even if she is not entirely conscious.
· Ask a bystander to call for help and ask the bystander to return and let you know if they have managed to do so. If you have a mobile or a bystander has, use it to call for help/ambulance/police.
· For someone who is unconscious, groggy or has fainted, DO NOT give them anything to eat or drink, as the person might choke.
· A doctor must be seen in all cases, but this is especially imperative if the person is unconscious, has seizures, displays abnormal behavior or there is blood in the urine or stools, or from the ear or nose after an accident.
· Find it, Fix it. (Find the problem and fix it)
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