ALL TRAUMA SUMMARY

What is suspension trauma and the suspension cascade, and how do we manage it?

• Pre-syncope or unconsciousness whilst suspended in harness

• Theory is venous circulation struggles to return due to suspension and harness

• Suspension cascade

  • 3-6 mins from being suspended, blood pools in legs unless activated by muscles

  • 6-12 mins → obstruction of venous return worsens, harness and abdominal pressure compresses inferior vena cava

  • Loss of consciousness follows

• If able to rescue, make patient supine

• If unable to reduce, elevate legs

What are the types of hanging?

• Short drop: death is caused by asphyxia due to compression of airway and blood vessels in neck

• Long drop: death is caused by fracture-dislocation of upper cervical vertebrae

Ensure you note height of drop if possible, and best assume they could have cervical injury

• Partial or fully supported

  • Some part of body or full part of body supported

How do we manage hangings?

• Identify if signs of life or need for resuscitation

• One person to hold patient and other to cut ligature

• Cut ligature not on the knot if possible

• Call for backup

• Move patient to appropriate position (consider C spine)

• Airway should take priority over C spine

• Airway management may be difficult, stiff and swollen

• If elect to perform resuscitation and have ROSC - aware they are hypoxic and agitated - need specialist care

What should we remember about welfare for Hangings?

Hangings are extremely psychologically traumatic. Seek help and accept help offered to you.

Keep in mind bystanders, witnesses and families who need signposting to support services as well.

What are the categories of Blast injuries?

• Primary

  • Blast shockwave

    • Blast lung, ruptured tympanic membrane, bowel perforations

• Secondary

  • Flying fragments/debris

    • Penetrating trauma and lacerations

• Tertiary

  • Blast wave propels patient against options

    • Burns, asphyxiation, toxic substances

• Quartenary

  • Other explosion related injury and illness

    • Burns, asphyxiation and toxic substances

• Quinary

  • Resulting from additives such as bacteria and radiation

    • Chemical burns, radiation and infection

Describe the difference between stab wounds and gunshot wounds, and what you must consider for each.

• Stab wounds

  • Low velocity

  • Multiple wounds from a single weapon

  • May leave only small external injury with significant inside damage (unknown what angle or length)

• Gunshot wounds

  • High velocity = more potential for injury

  • Projectile pathway often erratic

  • Result in cavitation

    • Permanent cavity by pathway of projectile

    • Large exit wound in comparison to entrance would

  • May result in ricochet

    • Erratic pathway, may not find exit wound. If no exit wound all kinetic energy transferred to body

  • Must consider

    • Scene safety

    • Weapon type

    • Structures on projectile path

    • Crime scene

    • Patient care is top priority

When can we as normal ambulances crews attempt a light rescue?

• If patient can be removed from harm safely (for yourself and patient) and condition requires immediate intervention. It is a last resort.

• Wear all appropriate PPE

• SBAR for help, work as a team, and request additional resources

What is the SCENE mnemonic?

Used on every scene to dynamically risk assess and pick up red flags, and communicate these to others:

S - Safety

C - Cause

E - Environment

N - Number of Patients

E - Extra resources

What is the SCENE mnemonic?

Used on every scene to dynamically risk assess and pick up red flags, and communicate these to others:

S - Safety

C - Cause

E - Environment

N - Number of Patients

E - Extra resources

What equipment do we have for light rescue?

• Scoop stretcher

• Fire extinguishers (2) small

• Safety helmets

• Hi Vis

• Debris gloves

• C-spine collar

• Splints

From additional resources:

• KED (Kendrick extrication device) to extricate from seated position (HART)

• PAX stretcher (SKED) (CTM, APP, HART)

What is the key for all max-fax injuries?

• Good airway management, postural if not possible to put in an adjunct or chin lift/jaw thrust

Describe orbital or ‘blow out’’ fractures, and what are some signs and symptoms?

A blow to the eye can cause orbit to ‘blow out’ and fracture

• Eyeball can retract into socket (enophthalmos)

• Eyeball can go out of the socket (exophthalmos)

• Double vision (diplopia) and/or loss of upward vision

• Pupils at different horizontal level to each other

• Loss of sensation above eyebrow and over cheek

Describe Maxilla fractures

Fractures to ‘upper jaw’ area going up around nose and under eyes

Why do max-fax injuries look worse than they often are, and what is the biggest complication?

• Lots of soft tissue

• Unlikely to cause hypovolaemia except in children

• Airway problems are the biggest complication - aspiration or haemorrhage

What do we need to be aware of for management of Maxillo-facial injuries in CONSCIOUS patients?

• Remember C-spine, may be necessary to remove debris from mouth. Consider postural drainage - sitting up and leaning forward

• Breathing - administer o2 if breathing spontaneously

• Circulation - if laceration through cheek, need pressure on both sides

• do NOT immobilise a mandible fracture - allow the patient to self support

What do we need to be aware of for management of Maxillo-facial injuries in CONSCIOUS patients?

• Consider postural drainage and/or suction - remember MILS though

• NP if tolerated but caution basal skull fracture

• No OP

• Advanced airway and pain management required - early advanced assistance requested

Describe types of eye injuries and how to manage them

• Chemical

  • Wear PPE and irrigate affected eye for 20 mins, do not contaminate unaffected eye (bad eye down)

  • Cover both eyes wth sterile dressings

• Corneal abrasion

  • Superficial. Requires ophthalmic assessment.

• Blunt trauma

  • Assess for visual acuity - ask pat to read text

  • Require examination oven if vision appears unaffected

• Foreign bodies

  • Small items like grit or eyelash can be safely rinsed out

    • If in upper eyelid - instruct pat to grasp eyelashes of upper lid and gently pull over lower lid

  • Any embedded object in cornea or intra-ocular do not move - convey to hospital

    • Cover both eyes with sterile dressings

    • Build up dressing around object to prevent movement

    • Do not try to remove or apply direct pressure

• Constant reassurance, remove contact lenses, cover both eyes, be wary of damage behind eyes (head or fracture of facial bones)

Describe nose bleeds and how we manage them

• Can be caused by nose-picking, direct trauma (consider child abuse), bleeding disorders, dry nose, blood thinners, high BP

• Management

  • Need to ask if one or both nostrils (Both suggest bleed higher up)

  • Instruct pat to sit down and lean forward

  • Ask patient to squeeze soft part of nose 10 mins

  • Advise to breathe through mouth and spit rather than swallow

  • After 10, ask to release pressure and reassess

  • Try again if not stopped until 30 mins passed

• Transport if:

  • Longer than 30 min bleed

  • On anticoagulant medications

  • Bleeding disorders

Describe ear-emergencies and management

• Types:

  • Foreign objects

  • Sudden Changes in air pressure

  • Loud noises

• Management

  • Ruptured ear drum

    • Place sterile cotton gently in outer ear canal

    • Remove to hospital

  • Cuts on outer ear

    • Apply direct pressure, cover injury with dressing, apply cold compress to reduce swelling

  • Drainage from inside of ear

    • Cover outside of ear with sterile dressings Build (tape in place)

    • Lie person down affected ear down so can drain (consider C-spine) and transport

• Do not:

  • Block any drainage from ear

  • Try to clean inside of ear canal

  • Put any liquid in ear

  • Attempt to remove object

What are common causes of traumatic brain injuries?

• RTCs

• Falls

• Assaults

• Direct blows to head

What are the two types of head injuries?

• Primary head injury

  • Instantaneous injury resulting from impact itself

  • E.g. cannot be undone, damage is done

• Secondary head injury

  • Injuries occurring after the event, I.e. from swelling, bleeding

  • E.g. good pre-hospital management can influence impact - recognise TBI may be present

What are complications of a TBI?

• Hypoxaemia

• Hypotension

• Intracerebral Haematoma

What signs may indicate a TBI - secondary head injury 1-3 hrs after incident?

• Wounds to head

• Boggy areas or depressed skull fractures (never put pressure)

• Visible fractures/deformity

• ‘Panda eyes, raccoon eyes’ - Bilateral Peri-orbital Ecchymosis - indicate ?fracture around eyes temple

• Bruising behind ear, around mastoid process, ‘battle’s sign’ - bleeding of base of skull ‘basal skull fracture’

• CSF or blood leaking from nose or ears

• Cushing’s Triad - raised BP, reduced HR, irregular respirations

• Dizziness

• Nausea & vomiting

• Abnormal pupils and or reaction

• Visual disturbances

• Severe headache

• Altered level of consciousness

• Repetitiveness

• Amnesia

• Paraesthesia/paralysis of extremities

• Posturing

• Abnormal respirations

Describe Cushing’s triad and how it can detect Intra-cranial pressure increases?

Cushing’s Triad includes increased systolic BP, decreased HR and irregular respirations.

• Bleeding in the brain increases intra-cranial pressure

• Systolic Blood pressure needs to increase to get the blood into the cranium (to overcome pressure gradient) via vasoconstriction

  • Will see a bigger gap between systolic and dyastolic BP

• Body notices vasoconstriction and decreases hr

• As BP increases, more blood goes into brain, increasing intra-cranial pressure even more

• Increased pressure pushes brain stem down and compresses it

• Damage to brain stem creates irregular respirations

Why are abnormal pupils or reactions an indication of TBIs?

• The nerves associated with eye movement and vision are very sensitive to intra-cranial pressures and are first to be affected

What is Paraesthesia?

Altered sensation

Why are scalp injuries in children a red flag?

Scalp injuries can cause hypovolaemia in children

• Children have less blood volume than adults

• Head is bigger in relation to their body

What GCS are associated with severity of brain injuries?

• 13-15 = mild traumatic brain injuries

• 8-12 = moderate traumatic head injuries

• 3-8 = severe traumatic brain injuries

What are the two types posturing?

• Decorticate posturing (flexion towards core)

• Decerebrate posturing (flexing away from core)

What should you always assume with a head injury?

• That there is an associated C-spine injury, so full immobilisation

Describe Cerebral contusions - and what is a coup/contrecoup pattern?

• Bruising and swelling of the brain itself -Since brain is closed box, pressure increases as brain swells, blood flow to brain decreases

• Coup pattern is the cerebral contusion caused by the brain hitting the skull in the direction of impact (e.g. when hit head forward in wall)

• Contrecoup pattern is cerebral contusion caused by brain hitting skill in opposite direction, the secondary impact (e.g. when head snaps back after hitting wall)

Describe the different types of intracranial haemorrhage as a complication of TBI

• Extradural (above Dura Mater - usually slower, may take many days to become fatal)

• Sub Dural Haemorrhage (below Dura Mater - usually slower, may take many days to become fatal if chronic)

  • Acute

  • Chronic

• Sub arachnoid haemorrhage (below Arachnoid Mater)

  • Usually happens very quickly and spreads very quickly

  • ‘Thunderclap headache’

  • May also present without trauma- ‘bleed’ stroke

Describe key things to remember for management of TBI

Remember that an isolated head injury does NOT cause hypotension or tachycardia. If you go to a head injury patient presenting with this it indicates other injuries are present!

• Immobilise

• Prevent hypoxia with O2

• Treatment hypotension

• Maintain EtCO2

• Transport patient quickly to definitive care

DO NOT

• apply pressure to depressed or open skull fractures

• Attempt to stop CSF or blood flow from ears or nose

What are the dangers of pelvic injuries?

• More likely to fracture in more than one place

• Large vasculature in area, can hold up to 5l of blood

• Can cause damage to other organs in abdomen

What are some causes of pelvic injuries?

• High energy transfer e.g. RTC

• Fall from height

• Crush injury

• Elderly

• Degenerative bone diseases

• Receiving radiotherapy

What are signs and symptoms of pelvic injuries?

• Bruising

• Bleeding from rectum, vagina or urethra

• Deformity

• Swelling

• Shortening of lower limb

• Pain over hips, groin or lower back

• Hypovolemic shock

• Altered sensation in one leg

Describe management of pelvic injuries

Time critical- DRABC and splint

• Consider C-spine when managing airway

• Control catastrophic haemorrhage

• High flow O2 - increased demand for oxygen in tissues

• Pelvic splint - immobilise knees and ankles as well

• Minimise movement when treating - limit log roll to 10 degrees

• Consider paramedic assistance

• Pain relief

• Smooth rapid removal to MTC

• Full observation

• Avoid repeated movements and never ‘spring’

  • Put thumbs on iliac crest to see if equal

  • Once pelvic splint has been placed- do not remove

Describe how to put on a pelvic binder

• Can be used in conjunction with traction splint if concurrent mid-shaft femur fracture. However, Pelvic Splint goes on first as traction is pulling on pelvis.

Why is C-Spine so important?

• Controls respiratory and circulation centres

  • Remember - ‘C3, 4 and 5 keeps the diaphragm alive’

• Also the connecting point for all other bodily function and movement below it

What mechanisms of injury can injure the spine?

One or more of:

• Hyperflexion

• Hyperextension

• Rotation

• Compression

What are types of spinal injuries?

• Dislocation of vertebrae

• Fracture of vertebrae

• Displacement of vertebrae (prolapse)

Describe spinal shock

After a spinal cord injury:

• State of complete loss of motor function, even if spinal cord still intact

• Can have possible loss of sensory function

• Can go on for considerable time

• Recovery may occur

Describe neurogenic shock

After spinal cord injury:

• Poor tissue perfusion

• Caused by sympathetic tone loss

Describe Cauda Equina sydndrome

• Severe compression or inflammation of spinal nerves in lowest region of spinal canal

• Onset can be acute (hours/days) or chronic

• It is a surgical emergency - urgent decompression required

• Any of following are red flags

  • Numbness in groin/perineum/buttocks (Saddle anesthesia)

  • Bladder or bowel dysfunction

  • Sexual dysfunction

  • Lower limb weakness and/or sensory deficit (disturbed gait/inability to walk)

  • Reduced or absent lower limb reflexes

Describe signs and symptoms of Spinal Injury

• Pain anywhere along spine

• Loss of sensation in limbs

• Loss of movement in limbs

• Altered sensation in trunk or limbs (pins needles/burning/electric shock)

• Hypotension With bradycardia in C-spine injuries

• Diaphragmatic or abnormal breathing

• Hypotension with warm peripheries or vasodilation

• Flaccid muscles (no tone) with absent reflexes

• Priapism

Describe management of spinal injury

• Safety

• CABCDE

• Maintain c spine with cervical collar or MILS

• Extricate to safe place for assessment

• Assess and manage pain

• Asses patient using immobilisation algorithm

• Immobilise entire spin if indicated (collar, blocks and scoop)

• Rescue/spinal boards are for extrication only

• If immobilisation not possible, use padding/support

• Use major trauma triage tool to determine conveyance

• Pre-alert the receiving hospital if necessary

• Carry out secondary survey if time permits

• Convey smoothly

What are some potential complications when managing a patient with a spinal injury

• Airway problems - increased risk of aspiration

• Increased intracranial pressure

• Restricted respiration

• Dysphagia (problems with swallowing)

• Skin ulceration/pressure sores

• Pain

What are important documentation elements for spinal injuries?

• Was MILS used to maintain c-spine

• How extricated

• Use of immobilisation algorithm

• Was entire spine assessed?

• Was immobilised? What equipment?

• Which Major Trauma Tool triggered if any?

What should you remember about abdominal trauma injury assessments?

• Can be difficult to assess

• Limited protection of organs of abdomen

• Identifying that trauma has occurred is more important that identifying what structure is affected

  • Grimacing/verbal communication of pain

  • Redness/bruising

  • Bleeding

  • MOI

  • EXPOSE EXPOSE EXPOSE

• Significant intra-abdominal trauma may not show signs immediately - don’t rule out on vital signs alone

What are the three anatomical areas of the abdomen?

• Abdominal cavity

• Pelvis

• Retro-peritoneal area (Posterior region where organs are fixed e.g. vena cava and aorta, duodenum, pancreas, kidneys ureters bladder)

What is the risk to the retro-peritoneal area in trauma?

As structures are fixed in place tightly to the abdominal wall, high risk of shearing and rupturing

What can an internal bleed in the abdominal cavity result in for surrounding organs?

• Bleeding in abdo cavity can put pressure on other organs like the stomach

• Not leaving enough space for diaphragm to expand, affecting breathing

What should you remember about penetrating objects, I.e., a knife?

• Length of penetrating objects, for risk of injury to adjacent organs

• If object in situ do not remove, secure object

  • If pulsating, allow movement of object but still secure and do not remove

How should you manage evisceration injuries?

• Do NOT push protruding organs back in

• Apply Blast Dressing - do not wet as will become cold

  • Place plastic sheet against organ

  • Secure using the conforming bandage

How should you manage all abdo trauma incidents?

• Administer O2 high flow

• Analgesia as required

• Monitor vitals

• Apply relevant dressings if required

• Transport to appropriate hospital

What are some abdominal trauma red flags?

• Cat haem

• Major primary survey problems

• Decrease LOC

• Shoulder tip pain

• Tachycardia

• Dyspnoea

• Sats <94%

• Hypotension

• Abdo distension and bruising

What is the most common problem associated with chest injuries?

• Hypoxia - caused by either impaired ventilation or secondary hypovolaemia

What else could be injured from a rib injury?

• Liver (rupture from right sided impact [floating ribs])

• Kidneys (rupture from trauma to back)

• Spleen (rupture from self sided impact [floating ribs])

• Stomach, pancreas, gall bladder (burst of fluids into body)

• Always remember could be neck or spinal injury (e.g. blunt high energy impact to chest can cause fractures of spine and c-spine)

What questions should you consider for chest injuries?

• MOI

  • Stabbed? Shot? (Entry/exit wound, object stuck)

  • Crushed or compressed? (Effect ventilation)

  • Driver hit wall at speed? (Speed, airbags, seatbelt, vehicle type)

  • Assault? (Weapon, blunt or sharp, LOC?)

  • Fall from height? Fallen onto anything? (How high, what fell on, how landed)

• Is the patient elderly, child or infant?

• Need LFB, MET or senior assistance?

What are possible signs and symptoms of a chest injury?

• Hypoxia, Dyspnoea, Tachypnoea, Bradypnoea

• Shallow respirations, use of accessory muscles

• Abnormal chest wall movement

• Deformity, bruising, swelling, wounds

• Pain, tenderness

• Obvious loss of blood, signs of clinical shock, haemothorax

• Reduced levels of consciousness

• Anxiety

What are some types of injuries caused by chest trauma?

• Deformity to chest wall structures may induce tearing and contusion to lungs and other structures causing respiratory problems and pain

• Myocardial contusion - caused by blunt trauma to sternum, may result in cardiac rhythm disturbanceS

• Haemothorax or pneumothorax

• Rapid deceleration causing sheering forces sufficient to rupture vessels such as aorta

Describe fractured ribs and complications

• Can cause dyspnoea

• Can cause 100-125ml blood loss

• Can cause further damage to soft tissues and organs

Describe a fractured sternum and complications

• Fracture in itself is not serious, but significant probability of other major injuries as force required to fracture is high

• Request clinician intervention/evaluate if patient time critical

Describe flail chest and complications

• Two or more rib and sternum fractures in two or more places

• Usually occurs from blunt trauma

• Flail segment will move inwards on inspiration and outwards on expiration → movement of underlying lung may become inadequately ventilated

• Bear in mind each rib fracture could result in up to 100-125ml blood loss

Describe signs and symptoms of pneumothorax, management and complications

Can be Spontaneous or Trauma caused:

• Spontaneous can be fine as long as remains a closed pneumothorax and does not progress to openhole

Types of Pneumothorax:

• Closed: visceral pleura is affected only. Common via spontaneous but can also be caused by trauma. Air goes into pleural space and can go back out via airways

• Open: parietal pleura affected. Caused by trauma, air goes into pleural space. If hole is large enough are can go back out. ‘Sucking chest wound’

• Tension: either visceral or parietal pleura affected, air can go in but can’t go out. As inspiration is active and expiration is passive, easy to get air in but difficult to get air out. Also, path of least resistance = bigger sized hole than trachea, air will enter here.

Tension pneumothorax:

• Eventually cause other structure to ‘shift’ away from pressure (e.g. tracheal deviation), put pressure on blood vessels returning blood to heart and to heart itself, causing obstructive shock.

• Symptoms:

  • Dyspnoea, tachycardia, hypotension

  • Reduced chest wall movement, reduced or absent breath sounds, distended neck veins, tracheal deviation

• Management

  • Chest seal, tension pneumothorax

• Time critical and life threatening

Describe signs and symptoms of haemothorax and complications

• Blood in thoracic (pleural) cavity

• Usually occurs form penetrating trauma injuring major blood vessels but could be blunt deceleration shearing injury

• As blood fills thoracic cavity takes up space normally occupied by lungs

• Results in hypoxia and hypovolaemia

• Signs and symptoms

  • Reduced lung sounds

  • Bruising at base of lungs

• Time critical and life threatening

Describe signs and symptoms of cardiac tamponade and complications

• Excessive fluid in pericardial sac compresses the heart limiting its ability to pump

• More common in penetrating injury

• Only requires 20-30ml of blood to cause tamponade

• Time critical and life threatening

How do we assess chest injuries using the medical model?

• DRCACBCDE - any major issues here?

  • If tachycardia or Tachypnoea - ?pneumothorax ?haemothorax

  • Cold peripheries, slow cap refill, pallor - ?internal bleeding of organ underlying ribs?

  • Does pat require other interventions? Request APP, HEMS, Hotel backup asap

  • Is patient time critical?

• Some major chest injuries will fail at B → if cannot correct, undertake time critical transfer to MTC

• EXPOSE THE CHEST

  • LOOK for wounds, swelling, deformity, bruising, chest wall movement, back of chest and axillary, neck distended veins and tracheal deviation

  • FEEL for punctures, deformities, instability, tenderness, depth and symmetry of movement

  • LISTEN for air entry

Describe signs and symptoms of Subcutaneous Emphysema and complications

• Associated with severe thoracic injury

  • Air travelling from pleura up airways under skin

• Signs and symptoms

  • May look like severe oedema, but feels like ‘fresh snow’ powdery soft feeling

Describe secondary survey for chest injuries

• On route to hospital if time critical

• Assess for all other injuries top to toe

• ECG

• Listen to chest sounds

• Pain score

• Thorough review of MOI

• PMHx

Describe management in AAP scope for chest injuries

• High flow o2 on non-rebreather

• Do NOT give entonox for chest injuries and a clinically suspected pneumothorax

  • Request paramedic intervention

• Wound dressing if required

  • Corius Seal Dressing

  • Fox Chest seal/russel chest seal (helps to avoid open pneumothorax from developing into tension pneumothorax to form, but cannot reverse a tension pneumothorax - lets air out but not in - if air trapped somewhere will need needle decompression)

    • Remember, lungs sit higher than you think.

    • Find highest and biggest wound, apply with window over top of puncture

    • DO NOT apply more than one chest seal

      • Block other punctures with a corius chest seal(cut to size), so air will flow out of the chest seal

What is the difference between direct and indirect forces in the context of MSK injuries?

• Direct: injury at point of impact when force is too great for soft tissue to absorb and dissipate (e.g. knee into dash causes patella fracture)

• Indirect: force applied to region of body and transmitted through skeleton until it reaches weakest point, causing bones to break (E.g. knee into dash, travels up femur to cause NOF fracture)

What are the types of fractures?

• Closed: sometime called simple, no puncture of skin

• Open: sometimes called compound, when bone puncturing skin (caution it may have gone back in; if break in skin and broken bone ?compound fracture)

What is a pathological fracture, and why should you be concerned?

• Caused by weakness of bones due to disease (e.g. osteoporosis, arthritis, cancers, bone disorders)

• A minor force can cause injury

• MOI may not be indicative of the injury (e.g. a simple fall or relatively minor blunt force)

Describe dislocations

• Abnormal separation of joint surfaces

• May occur alongside fractures or in isolation

• Muscles involved then spasm causing the joint to lock

• More likely to occur in synovial joints

Describe sprains and strains, and how we manage them

• Sprain - Ligamental injuries that involve partial or complete tear of ligament

• Strain - stretch and/or teat of muscle fibres and/or tendon

• Managed the same pre-hospital, immobilised and analgesia and transport

What are some possible complications from MSK injuries?

• Pain

• Mobility impacts (immediate and long term)

• Blood loss from fractures

• Further damage to surrounding tissue and nerves from movement of fractures

• Infection (particularly from open fractures)

• Compartment syndrome/ischaemia

What are some general signs and symptoms of MSK injury?

• Pain

• Swelling

• Deformity

• Erythema (redness)

• Reduced movement

How do we assess limbs in the context of MSK injuries?

• Neurovascular status is key, need to assess this before and after intervention

• MSC

  • Motor: ask the patient to move the limb

    • Negative may indicate nerve or ligament/tendon/muscular damage

  • Sensation: apply light touch, assess sensation (ask them to close eyes and touch both - feel normal and both sides feel same?)

    • Negative may indicate nerve damage

  • Circulation: distal pulses, skin temperature/cap refill

    • Abnormal ma indicate vascular compromise

• Any negatives in MSC indicate time critical

How do you identify limb ischaemia?

• 6 Ps - any one indication could indicate limb ischaemia

  • Pain - out of proportion to injury not eased by splinting or pain relief

  • Pallor - compromised blood flow to limb

  • Paralysis - loss of movement

  • Paraesthesia - changes in sensation

  • Pulselessness - loss of peripheral pulses which can lead to complete occlusion of circulation

  • Perishing cold - limb is cold to touch

Describe general management of MSK injuries

• Standard Primary survey assess and manage order

• Think about MOI

• Assess injury

• Pain management

• Remove jewellery/clothing

• Immobilise/splint injury

• Consider limb elevation/compress

Describe benefits of immobilisation/splinting

• Reduces pain

• Helps to slow bleeding

• Reduces risk of fat/air embolism

• Prevents further damage tov vessels/nerves

• Supports limb

• Reduces pressure on skin

• Prevents muscle spasm

How do we manage amputations, partial amputations and deglovings?

• Remove gross contamination (do not irrigate)

• Cover with a moist field dressing (both stump and part)

• Secure in a plastic bag

• Place bag on ice (avoid direct skin/ice contact)

• Cover/treat the stump (blast dressing)

How do we manage mid-shaft femur fractures?

• Manual traction

• Traction splint

  • Kendrick traction splint

    • Can be used alongside (over) pelvic splint

    • Should NOT be used where fractured ankle, rib-fib, neck of femur or significant knee injury

    • Method

      • Open (in trauma bag)

      • Place upper groin strap (with pole holes)

      • Place ankle strap (padded side along Achilles) and tighten with green strap

      • Put together pole, straight end up to belt level, L shaped end should be two segments below foot, shorten pole if needed

      • Attach yellow strap to L end

      • Secure straps at shin

      • Pull red tab to traction

• Time critical conveyance

What are signs of a NOF and how do we manage neck-of-femur fractures?

Signs and symptoms

• Shortening and rotation of leg

• Pain in hip/groin

• Referred pain in knee

Management

• Pain relief

• do NOT use pelvic blinder or traction splint

• Splint with other leg

  • Padding between legs (blanket)

  • Triangular bandages above and below knee to secure between legs (feed under angle of knee)

  • Figure of 8 around ankles

    • Use NO.2. Under ankles with equal length either side

    • Cross over feet

    • Tie under feet

How do you use a vacuum splint?

Wrap around injury and use suction to secure

How do you use a box splint?

• Ensure stability at joint above and below fracture

• Secure straps tightly, ensuring foot is secure as well

How do you use slings and when are they indicated?

• Fractures below the elbow (wrist, ulna, radius)

  • Arm across body may be most comfortable

  • Vacuum or box splint, piece of cardboard, magazine etc to go under forearm to support

  • Triangle bandage

    • Right angle of short edges sits at elbow

    • Posterior corner over far shoulder

    • Anterior corner over near shoulder

    • Adjust height as necessary

    • Tie half loop behind neck

    • Right angle loose bit tucked in or tied off to create a well

• Upper arm (shoulder dislocation, fractured humerus, collarbone)

  • Arm up across chest (hand at shoulder to dangle arm and take pressure off upper arm)

  • Triangle bandage

    • Right angle of short edges sits at elbow

    • Anterior corner over far shoulder

    • Posterior corner around back

    • Tying up around far shoulder

• Check MSC before and after application

Define burn, its types, and how it differs from a scald

• A burn is an injury caused by exposure to energy in the form of

  • Thermal (heat)

    • Scalds, flame injuries, contact burns

  • Electrical

    • Entry and exit point, touching energised source, lightning

  • Chemical

    • Corrosive agents (acids and alkali) and organic products (bitumen)

  • Radiation

    • Sunburn (UV), nuclear, ionised

• A scald is a burn caused by contact with a hot liquid or steam

How are burns classified?

• Erythema/superficial/first degree

  • Involves epidermis only

  • Local pain and redness

  • No blistering

  • Should heal within scar formation

• Partial thickness/second degree

  • Involves epidermis and dermis

  • Blistering

  • Very painful

  • Moist appearance

• Full thickness/third degree

  • Through all layers of dermis

  • White, waxen or charred

  • Will not heal without intervention

  • Destruction of tissue and blood supply

  • Damage to deeper structures (nerves, muscles, tendons)

  • No pain in full thickness wound itself (nerves completely destroyed)

  • Non blanching

Why are circumferential burns dangerous?

• Burns all around a limb or body part will constrict blood flow/tissue movement with no where to go (e.g. chest, neck - can restrict breathing)

What are burn red flags?

• Significant facial burns

• ABCD issues

• Airway burns/soot/oedema

• >15% adults and >10% children burns

• Hot gas inhalation

What are some key factors for assessing burns?

• Identify immediate complications

  • Infection

  • Hypotension (fluid moving to heal burns)

  • Inhalation injuries

  • Other significant injuries

• Assess burn severity

  • Location and size

  • Extent of the burn

  • Depth of the burn

• Consider possibility of non-accidental injury and child/adult safeguarding

What are some methods for assessing total burned surface area (TBSA)

• Wallace rule of 9s

  • Each area of patient’s body can be divided into multiples of 9

    • Head and neck 9%

    • Each lower limb 18%

    • Each upper limb 9%

    • Anterior torso 18%

    • Posterior torso 18%

    • Genitals 1%

• Mersey burns chart (via an app)

  • Shade over injured areas, can differential partial and full thickness, calculates an estimate %

• Using the patient’s palm (approx 1% of body surface area)

  • Useful for irregular/patchy burns

What are some challenges you could encounter with assessing burns and TBSA?

• In white skin, full thickness burns may be mistaken for unburnt skin

• In pigmented skin, superficial or dermal burns may not appear red

Using the medical model, what are specific considerations for burns in primary survey?

• D - do we need LFB/MPS? Windscreen report?

• R - AVPU and monitor continually for deterioration

• C - Don’t overlook distracting injuries (cat haem)

• A - any indication of → Airway burns, sooty marks, inhalation injury, strider, black sputum

• B - increased RR, wheezing, hoarseness, check JRCALC for O2

• C - Assess rate, CRT, signs of shock, distal pulses

• D - AVPU, pupils, glucose

• E - expedite removal, check trauma tool, expose to assess

Using the medical model, what are specific considerations for burns in Secondary Survey?

History:

• Time of burn, - any cooling/tx provided? Duration of burn?

• Mechanism/source- flame, object, contact time, chemical, oil, electrical

• Environment - Enclosed, outdoors, associate injuries

• SAMPLE

• Severity and character, exacerbating (relevant parts of SOCRATES)

• Co-morbidities - respiratory illness, CV disease, mobility, disease

• Social context - safe guarding? Vulnerabilities?

Examination:

• Head - asses for injuries

• Neck - TWELVE

• Chest - inspect (injuries/palpate), auscultate both sides (?equal ?wheezing?)

• Abdominal - inspect

• Neuro - reassess AVPU/gcs, MSCx4, pupils

• Limbs SLPIDUCT

• Expose and assess wounds and burns (caution for chemical burns not to spread when taking clothes off, or if stuck to skin)

Observations:

• AVPU/GCS for change

• Airway and breathing for degeneration

• RR, Auscultate, response to O2

• SpO2 and ETCO2

• Pulse and ECG

• BGL

• Pain managed effectively?

• Complete set to form baseline

Describe thermal burns management

• Manage ABCD issues first

• Signpost wheezing to senior clinician

• Cool burn for up to 20 minutes

  • Use running water (local stores, LFB, house), saline if water not available, burns dressing if not available

  • Don’t use ice cold water, aim for tepid/lukewarm

  • Cool the burn, not the patient

• Cling film (kept in dressings)

  • Discard first length (IPC)

  • Place sheets of cling film in a patchwork, do NOT wrap circumferential

  • Don’t use ointments/creams

  • Elevate if possible

• Provide analgesia

  • Entonox if indicated and no contras

  • Pain score and description befroe and after

  • Consider parts medic for further analgesia

• Cut off burned/smouldering material

• Remove constrictive items/jewellery

• Address any other injuries

How do we manage chemical burns differently to thermal burns?

• Do not investigate containers, spillages

• Remove clothing - cut it away rather than dragging off

• Irrigate for 20 mins but priorities hands, eyes, face, and be aware of runoff

• No cling film

• HART team notification

How do we manage taser injuries?

• Successful taser deployment is both a:

  • Electrical injury

  • Penetrating injury if skin broken

• Consider:

  • Do NOT remove barbs. Can cut wires but not barbs.

  • ICDs can be sensitive to low voltages

  • 12 lead monitoring is essential

  • Arrhythmias may develop after the incident