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PRINCIPLES OF

TRAUMA CARE
CELSO M. FIDEL, MD, FPCS,
FPSGS

LOVE your
CALLING with
PASSION.

It is the
MEANING of
your LIFE

Vehicular Accident

Smash up Cars

Truck involved in the Mishap

On the spot reporting

Primary Survey
Initial Assessment used to identify and
treat conditions that pose as immediate
treat to patients life.
Survey the scene; make sure that its
safe
Check for responsiveness by gently
shaking the patients shoulders and
asking him ARE YOU OKEY?

Primary Survey
4 Levels of Responsiveness

1. ALERT- awake, follows command, oriented as


to time, place and person
2. Verbal- speaks only when spoken to
3. Pain- respond only to painful stimulus
4. Unresponsive- does not respond to any
stimulus; eye closed; does not have any
verbal output; does not flinch when pain is
applied.

Primary Survey
WHAT DO YOU INITIALLY DO TO AN
INJURED PATIENT?
A. ENSURE ADEQUATE AIRWAY
B. BREATHING
C. CIRCULATION AND HEMORRHAGE
CONTROL
D. DISABILITY( NEUROLOGIC STATUS)
E. EXPOSURE OF THE PATIENT/
ENVIRONMENTAL FACTORS(COMPLETELY
UNDRESS THE PATIENT)

A, B, Cs of Basic Life Support

Primary Survey
A. ENSURE ADEQUATE AIRWAY
Responsive patient- if patient can speak the
airway is not obstructed.
Unresponsive patient- needs aggressive
airway maintenance immediately; make
sure airway is open and patient is breathing
adequately.
Trauma patient- establish adequate airway
and cervical spine control. Apply cervical
collar if needed.

AIRWAY PATENCY

Primary Survey
A. ENSURE ADEQUATE AIRWAY
Airway Obstruction Management
Advantages of OROTRACHEAL intubation
direct visualization of the vocal cords
ability to use larger diameter
endotracheal tubes
applicability to apneic patients
Operative
Intervention>CRICOTHYROIDOTOMY
only tubes < 6mm can be inserted

Primary Survey
A. ENSURE ADEQUATE AIRWAY
Airway Obstruction Management
Snoring and gurgling sound implies partial
.
PHARYNGEAL OCCLUSION; Hoarseness implies
LARYNGEAL OBSTRUCTION.
Nasotracheal intubation- for patients breathing
spontaneously.
Orotracheal intubation- for cervical spine injuries
provided manual in-line cervical immobilization
is
maintained.

REMOVAL of FOREIGN BODIES

Primary Survey
HOW DO WE MAINTAIN THE AIRWAY AND
SAFEGUARD THE CERVICAL SPINE?
Crash Helmet should be left in place until a cross
table x-Ray has been done and the cervical spine
cleared of any injury.
Orotracheal or nasotracheal airway can be helpful
Needle or Surgical Cricothyroidotomy is an easy,
fast and safe access to the airway.
Endo tracheal Intubation; best airway maintenance
device.

Primary Survey
HOW DO WE MAINTAIN THE AIRWAY AND SAFEGUARD
THE CERVICAL SPINE?
Keep airway patent w/o compromising spine
injury.
The AIRWAY must be cleared of blood, loose
teeth and dentures, or foreign bodies.
Do the JAW THRUST maneuver w/o hyperextension
of the head.( grasping the angles of the
lower jaw and displacing the mandible
forward)
Strap forehead of the victim on the stretcher
or any board used to immobilize the
patient with sandbags on both sides of the
head.

Methods of Opening Airway

Primary Survey
B. HOW DO WE ASSESS BREATHING?
Assess for adequacy of ventilation and
maximum gaseous exchange.
PATENCY of the AIRWAY does NOT mean
that VENTILATION is adequate.
Expose and examine the chest for rate &
depth.
Inspect and palpate the neck and chest for
evidence of external trauma, fractures,
tracheal deviation & disparity, subcutaneous
emphysema, lack of movement of hemithorax
Percuss for hyperresonance and dullness

Responsive patient- if patient can speak

the airway is not obstructed


Unresponsive patient- needs aggressive
airway maintenance immediately; make
sure airway is open and patient is
breathing adequately
Trauma patient- establish adequate airway and cervical spine control. Apply
cervical collar if needed

Primary Survey
B. BREATHING
ADEQUATE BREATHING
full rise and fall of chest
early breathing
normal respiratory rate 12-20/min
INADEQUATE BREATHING

insufficient rise and fall of the chest


increased respiratory rate
cyanosis of the skin, lips and nail beds
mental status changes
inadequate respiratory rate

Feeling for Breathing

Primary Survey
B. BREATHING
Remember cyanosis is a late sign, and should
not be relied upon to determine inadequacy
of ventilation
Measurement of end tidal CO2 is the most
sensitive indicator of adequacy of ventilation.
Causes of inadequacy of ventilation
Tension pneumothorax
Open pneumothorax
Flail chest/ pulmonary contusion

Primary Survey
B. BREATHING
Management
Commence 100% oxygen; Patients with
inadequate ventilation may require assisted
ventilation
Suction secretions
Tension/open pneumothorax management
Open pneumothorax should be closed by
plastic wrap, sealing only 3 sides
Taping of an examining glove with one
finger cut will allow the same.

Mouth to Mouth Resuscitation

Primary Survey

Tension/ Open Pneumothorax mgt. contd


If a sealed dressing must be done; CTT
must be done at a distant site.
Another maneuver is to seal the open
wound w/ vaselinized gauze. If not
capable of doing CTT a large bore needle
( 14 or 16) or a vascular cannula should
be placed at MCL 2nd intercostal space.
This should be connected IV tubing
dipped in a bowl of water.
Patient who is AGITATED in the absence of
head injury HYPOXIA.
In the presence of Head injury R/O hypoxia
as the cause of agitation.

Primary Survey
C. HOW DO WE ASSESS CIRCULATION ?
Not only controlling hemorrhage but, also
restoring adequate perfusion.
Skin perfusion( color, temperature, moisture,
capillary return). BLANCH TEST
Responsive PATIENT; Pulse rate, quality, and
regularity)
Appreciable pulse>> At least 80 mmHg
Systolic
Femoral pulse >>> At least 70 mmHg.
Systolic
Carotid Pulse >>>

60
.

Primary Survey
C. HOW DO WE ASSESS CIRCULATION ?
Irregular suggest ; cardiac abnormality
threading means HYPOXIA; cardiac rate
and rhythm; Check BP if possible.
Mental Status .Check consciousness level. In
the absence of head injury a fall in level
signifies>>>Diminished cerebral perfusion
Unresponsive patient- check carotid pulse;
Present if systolic pressure is 60 mm Hg.
Determine rate of external hemorrhage.

CIRCULATION

Primary Survey
WHAT ARE THE PRIORITIES OF HYPOVOLEMIC
SHOCK?
Gain access to the circulation
Rapidly transfuse fluids or volume expanders
Obtain blood samples and send for
BASELINE studies such as hematocrit,
typing and cross matching.
Replace Blood loss
Stop the Bleeding

Primary Survey
C. CIRCULATION & CONTROL OF
HEMORRHAGE
Management:
Control external hemorrhage by direct
pressure; No tourniquets/hemostats.

Insert 2 large intravenous catheters


Draw blood for CBC, blood typing, cross
matching, chemistries; arterial blood for
blood gases.

Rapid crystalloid infusion with warmed


Ringers Lactate solution.

Primary Survey
C. CIRCULATION & CONTROL OF
HEMORRHAGE
Management:
Apply pneumatic splint
Begin cardiac monitoring
Insert an indwelling catheter and
nasogastric tube unless contraindicated
Prevent hypothermia

CARDIOPULMONARY RESUSCITATION

Primary Survey
D. DISABILITY (DO BRIEF NEUROLOGIC EXAMINATIONS)
Determine level of consciousness
A Alert
V Vocal stimuli response
Can he speak?
Does he make sense?
P Pain stimuli response
U- Unresponsive

Primary Survey
Check Pupils
size; evidence of inequality
reaction
response to light
Sensory- can feel in all parts of body?
Motor- can move all limbs?

WHEN TO TRANSFER TO TRAUMA CENTER?


TRAUMA SCORING
For appropriate Triage
Hospital Transfer
Assurance of quality Care
PEDIATRIC TRAUMA SCALE
> 20 kgs
+2
Size
10-20 kgs
+1
< 10 kgs

Airway
Systolic Blood Pressure

NORMAL

+2

MAINTAINABLE +1
NOT MAINTAINABLE -1

> 90 mm Hg
50-90 mm Hg
< than 50 mm Hg

+2
+1
-1

WHEN TO TRANSFER TO TRAUMA CENTER?

>>TRAUMA SCORING
PEDIATRIC Trauma Scale>> In the
absence of proper size BP cuff,
Assess BP by assigning these
values:
Pulse palpable at Wrist>>>>>+2
Pulse palpable at Groin>>>>> +1
Pulse not Palpable>>>>>>>>>>> -1

WHEN TO TRANSFER TO TRAUMA CENTER?

>>TRAUMA SCORING

Central Nervous System Status


Awake>>>>>
+2
Partially Conscious or unconscious>
+1
Comatous or Decerebrate >>>>>>>>> -1
Open Wounds
None >>+2 Minor>>> +1 Major -1
Others
Skeletal Injury +2 Closed Fracture +1
Open/Multiple Fracture -1
SCORE 6-14 IF < 9 CRITERION FOR DIRECT
TRANSPORT Trauma Ctr.

WHEN TO TRANSFER TO TRAUMA CENTER?


>>TRAUMA SCORING
ADULT TRAUMA SCORE
1.SYSTOLIC BLOOD PRESSURE

3. Glasgow Coma Scale

4.EYE OPENING

> 89

13-16

Spontaneous

76-89

9-12

Opens on Command or

50-75

6-8

verbal stimuli

1-49

4-5

Response to pain

Nil

2. RESPIRATORY RATE

5. MOTOR RESPONSE

6. VERBAL

10-29

Obeys Command

Conscious, Coherent

> 29

Localizes Pain

Disoriented/Incoherent

6-9

Withdraws to Pain

Inappropriate Words

1-5

Abnormal Flexion

Incomprehensible Sounds

Abnormal Extension

Nil

IF THE PATIENT HAS A SCORE < 11 CRITERION for direct transport into a TERTIARY HOSPITAL OR
A TRAUMA CENTER.

WHEN TO TRANSFER TO TRAUMA CENTER?


WHAT ARE NECESSARY DURING TRANSFER?
Cervical Spine must be protected
Airway is maintained and breathing supported
Infusion must be started to support circulation
if necessary.
Control of external bleeding & immobilization
of the spine and fractures must be attained.
Locally, the best vehicle for transport in the
lieu of an ambulance is the jeepney.
The best backboard support is the backseat of
the of the jeepney too.

SECONDARY SURVEY
What are the Important points in the
HISTORY of TRAUMA VICTIMS?
Systematic Evaluation
S- Signs and symptoms
A- Allergies
M- Medications taken
P- Pertinent History
L- Last meal taken
E- Events preceeding the injury

SECONDARY SURVEY
Physical Examinations
Look for signs of injury

D- Deformities
O- Open injuries
T- Tenderness
S- Swelling

SECONDARY SURVEY
Physical Examinations Head to Toe
Examination of the Head
A. Scalp and Skull ;Look for signs of injury

D- Deformities
O- Open injuries
T- Tenderness
S- Swelling

SECONDARY SURVEY
A. Scalp and Skull
Brisk bleeding= rapid suture closure
Nasopharyngeal bleeding= French
20 foley catheter
Ecchymosis about the ear (battle sign); or
about the eyes (raccoon eyes)= presumptive
evidence of BASAL SKULL FRACTURE

SECONDARY SURVEY
B. Pupils
Symmetry
Reactivity
Size
C. Ears and Nose
Blood or Fluid from opening

SECONDARY SURVEY
D. Mouth
D- Deformities
O- Open Injuries
T- Tenderness
S- Swelling
F- Foreign Bodies

SECONDARY SURVEY
A. Examination of the Neck
D- Deformities
O- Open Injuries
T- Tenderness
S- Swelling
B. Cervical Vertebrae
Deformities
Palpate for step-up Deformities

SECONDARY SURVEY
Examination of the Chest; Check for
Symmetry of Expansion
Breath Sounds
Abrasions
Subcutaneous Emphysema
Open Wounds
Rib or Clavicular Fracture

SECONDARY SURVEY
Examination of the Abdomen
A. Inspection
Deformities; Abdominal Distension
Open Injuries
Protruding Organs
Swelling & Discoloration

SECONDARY SURVEY
B. Palpation
Rigidity ( Hardness)
Tenderness
Masses
C. Auscultation
Listen for bowel sounds

SECONDARY SURVEY
Diagnostic Aids for the Abdomen
Diagnostic Peritoneal Lavage for
suspected blunt injury
One shot IVP if GU injury is suspected
A Cystogram may be done by clamping
the catheter
CT scan if accessible and available can
be done on stable patients

SECONDARY SURVEY
Examination of the Pelvis and Rectum
Check for scrotal hematoma
Check for blood in the urethral meatus
Check for a high lying prostate
Blood on rectal exams may indicate injury to
the rectum or neighboring organs
Blood in the vagina vault or introitus
may indicate pelvic fracture

SECONDARY SURVEY
Examination of the Back
A. Inspection
Chest Wall deformities
Open Injuries
Foreign Objects
Dislocation
B. Palpation
Palpate for deformities along spine
Tenderness

SECONDARY SURVEY
Examine Upper & Lower Extremities
A. Inspection
>> Deformities, Open injuries, Swelling
>> Color
>> Motion, Wiggle test
>> Sensation
B. Palpation
>> Tenderness
>> Crepitation
>> Deformities

SECONDARY SURVEY
Measuring Vital Signs
1. Respiration

2. Pulse Rate
3. Blood Pressure
Increased BP
1. Cold environment
2. Stress; Pain
3. Smoking
4. Caffeine
5. Decongestant

Decreased BP
1. Heart failure
2. Trauma
3. Shock

SECONDARY SURVEY
Pupils
Normal Findings
Abnormal Findings
> constricts when >> No reaction to
exposed to sunlight
light
>> Remains constricted
>Dilate with less
>> Fixed, dilated or
light
unequal
>Should be of the same size

SECONDARY SURVEY
ESSENTIAL LAB. PROCEDURES
Baseline Hematocrit, Blood Typing, and Cross
Matching.
A cross table x-Ray of the cervical spine w/o
the victim being hyperextended. Swimmers
view if not possible; x-Ray tube positioned at
axilla directed to C-7. It will view lower
Cervical vertebra and T1.

SECONDARY SURVEY
WHERE and HOW do WE LOOK for Blood Loss?
There are three sites for exsanguinating
hemorrhage:
CHEST
ABDOMEN
THIGH (2-3 liters of blood in Hematoma)

SECONDARY SURVEY
Patients with injury to these sites; Thoracic is
1st followed by Abdomen then extremities.
Control of life threatening activities takes
precedence over limb salvage.
Chest x-Ray important especially looking for
sites of blood loss.

Other concerns in care of Casualties


Is INFECTION A RISK IN TRAUMA?

It is the leading cause of death occurring


beyond 2 days following trauma.
Prevent Infection by:
Repair or Restore mechanical structures
and barriers to bacterial contamination.
Support of Host defense > restoring
circulating blood volume, adequate tissue
oxygenation & nutritional support.
Appropriate use of ANTIBIOTICS.

Other concerns in care of Casualties


WHAT are the ANTIBIOTICS used IN TRAUMA?

Penicillin derivatives (Cloxacillin; Ampicillin)


for superficial wounds.
1st generation Cephalosporins & Clindamycin
for more severe injuries.
For Multiple injuries:
Broad spectrum Antibiotics for both gram
& gram positive aerobes such as:
2nd generation Cephalosporins
Aminoglycosides
4fluoroquinolones w/ Metronidazole

Other concerns in care of Casualties


WHAT are the ANTIBIOTICS used IN TRAUMA?

. For intra Abdominal Trauma


Ampicillin and Beta lactamase Inhibitors
Broad Spectrum penicillins & Beta lactamase
Inhibitors.
Carbapenims
Cefoxitin

Other concerns in care of Casualties


HOW DO WE GIVE TETANUS PROPHYLAXIS?

Tetanus prone wound:


Wound > 6hours old
> 1 cm. deep caused by missile or Crushing
injury.
Burn or Frostbite with:
Signs of infection
Divitalized Tissue
Contaminants

Other concerns in care of Casualties


Adequately Immunized Patients
A. Last dose w/in 5 years>>> All Wounds >> NONE
B. Last dose w/in 10 years:
Non Tetanus prone wound>>> NONE
Tetanus prone Wound>>>> Toxoid
C. Last dose > 10 years >> All Wounds >>> Toxoid
Inadequately Immunized Patients
Non Tetanus Prone Wound>>>>
Toxoid
Tetanus prone Wound>>>Toxoid and Antitoxin
after one to 12 months>>
Toxoid

HEAD INJURIES
All injuries to the head are potentially
dangerous
Proper assessment of consciousness
>> If impaired
Damage to the brain
Damage to the vessel inside the skull
Skull fracture

HEAD INJURIES
I.CONCUSSION
Widespread but temporary disturbance of the
brain due to a violent blow to the head.
A. REGOGNITION
1. Dizziness or nausea on recovery
2. Loss of memory of events at the time
of or immediately preceeding the injury
3. Mild generalized headache

HEAD INJURIES
II. SKULL FRACTURE
1. Suspected in patients of trauma with a
head wound
2. There maybe brain damage & bacteria
may pass thru easily
3. Patient is unconscious after head injury

INDICATORS OF POSTERIOR BRAIN INJURY

Vomiting
Blurred vision
Headache
Neck and back pain
Dizziness
Confusion
Any obvious depression or break in the skull
Any obvious sign or bleeding including
periorbital swelling and/or hematoma
Fluid dripping from the ears or nose

HEAD INJURIES
III. CEREBRAL COMPRESSION
Very serious condition requiring surgery
Occurs when a pressure is exerted on the brain
within the skull due to:
accumulation of blood
swelling of the injured brain
Associated with head injury and skull fracture
Maybe associated with stroke, infection and
brain
tumor

HEAD INJURIES
A. RECOGNITION

1. Recent head injury followed by full


recovery.
2. Deterioration of level of response, patient
becomes disoriented.
3. Intense headache
4. Slow, yet full and strong pulses
5. Unequal or dilated pupils

HEAD INJURIES

6. Weakness or paralysis on one side of the


face or body
7. High temperature or flushed face
8. Drowsiness
9. Obvious change in personality or behavior
such as irritability.

PATIENTS WITH HISTORY OF HEAD TRAUMA


1. Do a basic assessment of the patient
Is the patient awake
a. If patient is unconscious, make sure that
the patient has a patent airway and is
breathing adequately
b. Is the breathing normal
c. Is there a pulse
2.Check for spinal cord injury
a. If there is suspicion of possible brain
injury, assume cervical spine fracture
unless proven otherwise.

PATIENTS WITH HISTORY OF HEAD TRAUMA

b. Immobilize patients head by applying


cervical collar or placing sandbags and
strapping him to the backboard
3. Control any bleeding in the scalp . Look for
other injuries and treat them:
a. If there is discharge from an ear, position
the patient so that the affected ear is
lower. Cover the ear with sterile dressing
or clean pad, lightly secured with a
bandage. DO NOT PLUG THE EAR.

PATIENTS WITH HISTORY OF HEAD TRAUMA


In case of open skull fracture
Clean the wound with water.
Cover exposed area with clean material.
Do not attempt to reposition bone fragment.
DO NOT remove impaled objects. Make a
fluffy dressing around the impaled
object to stabilize it.
4. If patient is conscious, make him comfortable
by raising head and shoulders.

PATIENTS WITH HISTORY OF HEAD TRAUMA


5. If patient is unconscious maintain

immobilization and support ABC. Turn to


side if patient vomits to avoid aspiration
but maintain head & neck immobilization.

6. Call for an ambulance or medical team.

Monitor and record breathing, pulse and


level of response every 10 minutes until
help arrives.

BLEEDING FLOW CHART


1.LOCATE BLEEDING SITE
2. APPLY DIRECT PRESSURE ON THE WOUND
BLEEDING STOPPED ?

NO

YES

3. ELEVATE EXTREMITY ABOVE


CASUALTYs HEART
4. LOCATE PRESSURE POINTS &
APPLY PRESSURE; KEEP
PRESSURE OVER WOUNDS
TREAT SHOCK

BLEEDING FROM ARM OR LEG


YES

YES

BLEEDING STOPPED?

5. TREAT FOR SHOCK


CARE FOR WOUND
SEEK MEDICAL ATTENTION

NO
BLEEDING STOPPED?

YES

NO

NO

7. SEEK MEDICAL

6. APPLY TOURNIQUE AS LAST


RESORT

ATTENTION

HEAD INJURIES
1. CHECK ABCs & TREAT ACORDINGLY
2. CHECK FOR POSSIBLE SPINAL
INJURY
IMMOBILIZE HEAD AND NECK

HEAD BLEEDING

YES

N
O

5. RAISE VICTIMS HEAD&


SHOULDERS IF NO
SPINAL INJURY & NOT
IN SHOCK

NO

3. DIRECT PRESSURE OVER THE


WOUND. If FRACTURE SUSPECTED
APPLY PRESSURE TO OUTER EDGES
OF THE INTACT BONE

4. DO NOT REMOVE IMPALED OBJECT

UNCONSCIOUS
YES

7. SEEK IMMEDIATE MEDICAL ATTENTION


IF W/ SIGNS OF POSSIBLE BRAIN INJURY

6 KEEP PATIENT LYING ON THE


GROUND

ABDOMINAL INJURIES Flow Chart


1.CHECK ABCs and TREAT ACCORDINGLY

NO

PENETRATING WOUNDS

YES

NO

YES
IMPALED OBJECTS

NO

PROTRUDING ORGANS ?

YES
2. DO NOT REMOVE OBJECT
Stabilize subject

3. DO NOT RE-INSERT ORGAN


DO NOT TOUCH ORGAN
COVER W/ MOIST CLEAN DRESSING
BLOW TO ABDOMEN ?
5. SEEK MEDICAL
ATTENTION
4. ROLL VICTIM TO ONE
SIDE IN CASE OF VOMITING

Treatment of Abdominal Injuries


Lay the casualty down on his back with his

knees in upright position


Check the airway, breathing and circulation,

resuscitate if necessary
Impaled objects should not be removed
and should be stabilized by bunching
dressing around it then fixed with
adhesive tape
Protruding intestine should be covered
to prevent drying. If casualty coughs
prevent further protrusion by pressing
on the moist dressing

Treatment of Abdominal Injuries


Do not touch with bare hands any exposed
organ nor push them back into the abdomen
If casualty suffered from a blunt abdominal
injury, turn him to one side, preferably on
his injured side or in sitting position which
ever makes breathing easier
Do not give the victim anything to eat or drink
however you can moisten lips
Call for an ambulance or medical team. Treat
patient with shock. Stay with the casualty
and check his or her condition every few
minutes until help comes

Penetrating Chest Wound Sucking Chest Wound


A penetrating chest wound can cause internal
damage w/in the chest and upper abdomen.
Air can enter the thoracic cavity which has
a negative pressure. Lung on the side of
wound injury will collapse. If pressure builds
up to some extent it may prevent the heart
from refilling properly w/ blood, impairing
circulation and causing shock. ( Tension
pneumothorax)

Penetrating Chest Wound Sucking Chest Wound


RECOGNITION
1. Difficult and painful breathing
2. Breathing maybe rapid, shallow & uneven
3. Casualty has a feeling of impending doom
There may also be:
1. Signs of shock
2. Coughing up frothy, red blood
3. Grey-blue color of mouth, lips, nailbeds & skin
4. Crackling feeling of the skin around the site
of wound caused by air around the tissues

CHEST INJURIES
Flow Chart
CHECK ABCs and TREAT ACCORDINGLY
NO

YES

PENETRATING WOUNDS
NO

NO

SUCKING
CHEST WOUNDS

IMPALED OBJECTS

YES

YES
DO NOT REMOVE OBJECT
Stabilize subject

SEAL WOUND
TO PREVEN T
AIR TO ENTER

RIB FRACTURE

5.SEEK MEDICAL
ATTENTION
4. STABILIZE RIBS
and CHEST

Treatment of Chest Injuries


Check the ABCs and be ready to resuscitate
if necessary. Provide firm support for a
conscious casualty, in the position he finds
most comfortable.
Impaled objects should be stabilized
Place a plastic film on a sucking chest wound
and secure the three sides w/ adhesive tape
which ensures a one way valve
Stabilize a fractured rib by applying sling and
swathe

Treatment of Chest Injuries


Call for an ambulance or medical team. Treat
the patient for shock. Stay with him and
check his condition every few minutes until
help comes.
If the patient becomes unconscious, open the
airway and check breathing. Be ready to
resuscitate if needed; Place him lying with
injured side uppermost.
Do not probe, clean, or remove foreign body,
stuck clothing to chest wound.

AVULSIONS
Wash and clean wound
Control bleeding by direct pressure
Compression dressing
Call an ambulance or medical team.
or bring the patient to a hospital

AMPUTATIONS
Amputation is forceful partial or complete

removal of a limb. It is sometimes


possible to replant the amputated
part so, its important to locate and
preserve it. The sooner the casualty
and the severed part reaches the
hospital, the better.

AMPUTATIONS

CARE OF THE CASUALTY


Control blood loss by direct pressure &
raising the injured part. Do not use a
tourniquet
Apply a sterile dressing or non fluffy
clean pad secured with a bandage
Treat the casualty for shock
Call for an ambulance or medical team

AMPUTATIONS
CARE OF THE AMPUTATED PART
Wrap the severed part in a plastic bag
Wrap again in gauze or soft fabric,
place in another container filled with
crushed ice
Clearly mark the package w/ casualtys
name time of injury and give it
personally to the medical personnel.

Impalement
This is a condition wherein a foreign
object is protruding from a casualtys
body
1. Do not remove the impaled object
unless it is impaled in the cheek or
affecting the airway or CPR
2. Check the airway & breathing. Be
ready to resuscitate if necessary

Impalement
3. Check the airway & breathing. Be
ready to resuscitate if necessary
4. Control the bleeding
5. Prevent further injury by stabilizing
the object with bulky dressing, then
applying bandage
6. Call an ambulance or a medical team

Gunshot Wounds
Military gunshot wounds are often heavily
contaminated with delays in treatment.
The severity of the wound does not
depend on the velocity of the bullet but
depends on the amount of kinetic
energ transferred to the tissues. .

Gunshot Wounds
. How to Manage:

1. Check for ABCs. Resuscitate if necessary


2. Control bleeding by direct pressure
on the wound
3. Stabilize injured part if extremity is
affected. Insert an intravenous access
4. Cover wound w/ clean, sterile dressing.
5.Transport immediately for wound
debridement, Tetanus prophylaxis &
antibiotic coverage.

Crushing Injuries
Common among casualties who
have been crushed beneath debris
because of explosives, natural disasters,
or vehicular disasters. They are at
risk of developing Crush Syndrome
or traumatic rhabdomyolysis resulting
from skeletal muscle injury with
release of muscle cell content into
the general circulation.

Crushing Injuries

Local injuries includes fractures, swelling,


blisters, internal bleeding. The crushing force
may also impair the circulation, causing
numbness at or below the site of injury; no
detectable pulse in the crushed limb.

Dangers of Prolonged Crushing


Shock- If pressure is removed, tissue fluids
may leak into the damage muscle tissue.
Crush Syndrome- Toxic substances from
damage tissues are suddenly released. This
is extremely serious and fatal.

Crushing Injuries
TREATMENT for CRUSHING VICTIMS
Casualties Crushed for less than 10 minutes
Release the casualty as quickly as possible
Control external bleeding & cover wound
Secure & support suspected fracture
Examine & observe for shock; Treat
accordingly
Call for an ambulance. Insert an IV
line

Crushing Injuries
TREATMENT for CRUSHING VICTIMS
Casualties Crushed for more than 10
minutes
Call for an ambulance or medical team
Insert an IV line while waiting for an
ambulance
Comfort and reassure casualty until
help comes

Blast Injury
Injuries Sustained in Blast Explosions
1. Rupture of the Tympanic Membrane=
Ear pain;ringing in the ears; hearing
loss
2. Respiratory Effects= Inhalation injury;
airway hemorrhage
3. Skull Fractures
4. Burns
5.Fractures

Blast Injury
Injuries Sustained in Blast Explosions
6. Traumatic Brain Injury
7. Arterial Air Emboli= Confusion;
disorientation; focal neurologic signs

Blast Injury
TREATMENT of VICTIMS in Blast Explosions
1. Lay the casualty on the ground. Reassure
patient.
2. Maintain an open airway. Check breathing.
Be ready to resuscitate if necessary.
3. Control bleeding; Cover wounds with clean
and if possible sterile dressing. May apply
a cervical collar if neck injury is suspected.
4. Call an ambulance or medical team; May
start an intravenous line if trained to do so.
5. Continuously monitor patient until help arrives

Eye Wounds
The Eye can be bruised or cut by direct blows
or by sharp, chipped fragments of metal &
glass. All eye injuries are potentially
serious. Corneal injury can lead to scarring
with resultant loss of vision. There may be
rupture of the eyeball.
RECOGNITION
Visible Wound
Bloodshot appearance to the injured eye
Partial or total loss of vision
Leakage of blood or fluid from the wound

Eye Wounds

TREATMENT
1. Lay the casualty down on his back, holding
his head to keep it as still as possible.
2.Tell the casualty, keep both eyes still;
movement of the good eye will cause
movement of the injured eye; Do not
touch, attempt to remove an embedded
foreign body.
3. Ask the casualty to hold an eye pad over
injured eye. Bandage the pad in place.
4. Take or send the casualty to a hospital.

Internal Bleeding
TREATMENT
1. Help the casualty to lie down; raise and
support his legs. Loosen clothing at the
neck, chest and waist. If unconscious
place him with injury uppermost.
2. Call for an ambulance or a medical team.
3. Insulate him from the cold. Monitor and
record breathing, pulse and level of
response every 10 minutes.
4. Note the type, amount and source of blood
loss coming from bony orifices.

Bleeding At Special Sites

1.

2.

1.
2.
3.
4.
5.

Scalp and Head Wounds


It has a rich blood supply, when damaged,
the skin splits >>gaping wound>> profuse
bleeding.
May be part of a more serious underlying
injury>> skull fracture
TREATMENT
With gloves replace displaced skin flaps
Direct pressure over sterile dressing on wound
Secure dressing w/ roller bandage
If unconscious, open airway; Check BCs
Send casualty to Hospital

Bleeding At Special Sites


Wounds To The Palm
Richly supplied with blood, wound bleed
profusely; Deep wound may severe
tendons and nerves.
TREATMENT
1. Press a clean pad or sterile dressing firmly
into the palm and let him clench his fist
over it. If he finds it difficult to press hard,
let him use the uninjured hand to grasp it.
2. Bandage the casualtys fingers so they are
clenched over the pad. Tie knot over fingers.
3. Support arm w/ elevation sling; Send to hospital

Bleeding At Special Sites

Wounds To The Joint Creases


Major vessels cross the inside of the elbow and
knee; if severed will bleed profusely.
TREATMENT
Press a clean pad over the injury. Bend the
joint as firmly as possible.
With the joint firmly bent to press on the pad,
raise the limb. If possible, lay casualty
down to reduce shock.
Take or send the casualty to hospital; Release
the pressure briefly every 10 minutes to
restore normal blood flow

Bleeding At Special Sites

Bleeding From The Ear


Bleeding that originates from inside the ear
generally follows a ruptured eardrum which
may be caused by explosion. Sharp pain is
experienced followed by earache & deafness.
From a head injury blood may appear thin &
watery w/c is serious >> CSF leaking from brain.
TREATMENT
1. Help victim into half sitting position, head
inclined to the injured side
2. Cover the ear with a sterile dressing or clean pad
3. Send or take the casualty to the hospital

Bleeding At Special Sites

Bleeding From The Mouth


It usually originates from cuts from the
tongue, lips, or lining of the mouth usually
from victims teeth. Bleeding can be profuse
and alarming.
TREATMENT
1. Sit the casualty down, with their head forward &
inclined towards the injured side to allow
blood to drain.
2. Ask victim to press the wound between
thumb & finger w/ a gauze pad over the wound.

Bleeding At Special Sites


3. If bleeding persists, replace the pad with a
fresh one. Tell victim to let escaping blood
dribble; If swallowed it may induce vomiting.
4. Do not wash the mouth as this may disturb
a clot.
5. Advise casualty to avoid hot drinks for 12
hours.
6. If the wound is large or bleeding persists
beyond 30 minutes, or recurs; seek
medical or dental consultation.

Bleeding At Special Sites

Nosebleeds
Most commonly occurs when blood vessels
inside the nostrils rupture. It is usually
unpleasant, but can be dangerous if casualty
loses a lot of blood. Thin & watery nosebleeds
after head injury is serious problem= CSF leakage.
TREATMENT
1. Sit the casualty down with his head held
forward. Do Not let his head tip back; blood
may run down his throat and induce vomiting.

Bleeding At Special Sites


2. Ask the casualty to breathe thru his mouth,
(calm effect) and to pinch nose just below
the bridge. Help him if necessary.
3. Tell him not to speak, swallow, cough, spit,
sniff, as it disturbs a blood clot. Give him a
clean cloth or tissue to mop up dribble.
4. After 10 minutes, tell the casualty to release
the pressure. If his nose is still bleeding,
reapply the pressure for further periods of
10 minutes.

Bleeding At Special Sites


4. If it persists beyond 30 minutes, take or send
the casualty to hospital.
5. Once the bleeding is under control, and with
the casualty still leaning forward, clean
gently around his nose and mouth with
lukewarm water.
6. Advise the casualty to rest quietly for a few
hours and to avoid exertion and, in
particular, not to blow his nose, as this will
disturb any clot.

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