Injury Management and Shock
Trauma can result in bleeding, broken bones and/or internal tissue damage. These events when more serious can lead to shock developing or further risk of spinal damage. In this module we will look at what first aiders can do to help.
Trauma that results in bleeding can carry a very wide range of risks from very little to life threatening. Always remember serious bleeding injuries are part of your primary survey - DR ABCirculation.
Here we'll show you how to judge the severity of the bleed and treat accordingly.
Arteries carry blood directly from the heart. They are large blood vessels with blood flowing under pressure as a result of the heartbeat. As such if they are severed or rupture, blood loss occurs rapidly. Blood may squirt or pulse from an open wound. This is a very serious bleed and requires immediate treatment.
Veins are blood vessels that return blood to the heart from the various organs. They can also be large vessels but there is no blood pressure and blood flows only as a result of skeletal muscle contraction. Should they be wounded, blood can also be lost rapidly and may be observed flowing from the wound.
Capillaries are the smallest of blood vessels and this is where oxygen and nutrient exchange takes place. Blood moves very slowly through these vessels. Minor cuts usually result in capillary bleeds. Blood may ooze slowly from a wound.
Another way to judge the wound is described as CLIPS
- Contusion (Bruising) – blood vessels under the skin have been ruptured and bleed into the tissues. No external bleeding has occurred and the body will heal itself over time.
- Laceration – a jagged opening of the skin.
- Incision – a straight neat wound usually casued by a sharp implement (knife).
- Puncture – a pointed wound where an object has inserted into the tissue.
- Special – A wound that does not fit any category above. This could be a gunshot wound, with entry and exit points for example.
Regardless of the wound, your treatment plan as a first aider will follow a similar protocol. First and foremost ensure that it is safe for you to treat the casualty – turn off machinery and don latex gloves before handling the wound to protect you and the casualty from cross-infection.
- Position the casualty appropriately (sit down)
- Elevate the extremity
- Examine the wound to enable a decision on an appropriate bandage.
- Pressure – apply direct pressure to the wound
Apply a secure sterile dressing to the wound and add more dressings, layer on layer until the bleeding stops. Call 112/999 as necessary.
Monitor vital signs and be alive to signs of shock.
Shock is a condition in which circulation of the blood is not functioning normally. There are many different causes which are beyond the scope of the First Aid Responder. We shall focus on two:
- Hypovolemic Shock
- Harness-Induced Suspension Trauma
- An emergency condition in which severe blood or fluid loss renders the heart unable to pump enough blood to the body.
- Bleeding from serious cuts or wounds
- Bleeding from blunt traumatic injuries
- Internal bleeding
- Bleeding from digestive tract
- Significant vaginal bleeding
Initially: Pale face, Cold & clammy, Sweating, Rapid weak pulse
As shock develops: Cyanosis, Weakness dizziness, Nausea vomiting, Thirst, Rapid and shallow respiration
Late stages: Restlessness and aggressiveness, Yawning and gasping for air, Unconsciousness
- Ensure responder safety
- Dial for 112/999
- Open airway
- Treat any possible causes of shock
- Lay casualty down on a blanket
- Raise and support legs
- Loosen tight clothing at the neck, chest and waist
- Keep casualty warm
- Monitor vital signs
- If unconscious put in recovery
- Stay with patient until emergency services arrive
What – Where a fall has been arrested by rope/harness
Cause – Lack of circulation associated with being suspended in the harness
- Ensure personal safety & call 999/112
- Advise patient to move legs
- Elevate lower limbs if possible during rescue
- Place patient in a horizontal position as soon as possible
- Monitor vital signs
- Transport to Emergency Department
Limb injuries are a frequent occurrence through a number of scenarios. Sporting accidents or clashes, slips or falls in the workplace or twisting and awkward movements. The injuries can be categorized into three groups:
Fractures occur when a bone is cracked or broken. They are typically closed i.e. internal and remaining under the skin but can at times be open, where the broken bone punctures through the skin and protrudes externally.
- Loss of movement
- Severe pain
One of the key goals of the First Aider when assisting a casualty with a suspected broken bone is to minimize movement.
Movement may cause further damage to nerves, blood vessels or internal organs.
As with all first aid events, ensure that it is safe for you to proceed. Communicate with the injured person appropriately to understand better the extent of the injury and to reassure. Examine the suspected fracture site but do not move. If there is an open wound dress this appropriately as described previously.
Communicate a plan to the casualty i.e. 112/999 or arrange appropriate transport. Stabilize the limb using a splint or sling. Place some padding around injury for extra support, ensuring no excessive movement.
Maintain care until handover and observe for signs of shock.
Dislocations describe when a bone has been forced out of position at the joint. Joints that are more commonly dislocated are the shoulder and fingers.
The title ‘head to toe’ survey can feel quite daunting for the First Aid Responder. Contrary to assessing the patient fully from head to toe, a better description is to assess visually and physically as the event history dictates. Depending on the events leading to the injury or illness as well as the signs and symptoms, you may feel it helpful to examine a particular area of the patients body to determine if there are any further signs indicating the need for treatment. These can include:
- Nerves or blood vessels may become trapped within the repositioned joint
- The soft tissue damage around the joint may be damaged further
- Ineffective repositioning may prolong treatment and recovery time
Rest – assist the person to assume a safe resting position
Ice – apply an ice pack to the affected area
Support – help the person to support the affected limb – consider applying a sling
Soft Tissue Injuries:
Soft tissue injuries describes when muscles, ligaments and/or tendons are overstretched torn or ripped from their attachment to muscle or bone. They are usually accompanied by some minor internal bleeding (bruising).
- Pain and Tenderness
- Difficulty in moving the injured limb
- Swelling and bruising around the affected area
Ensure your safety.
Use the RICE acronym to guide your efforts:
- Rest – assist the person to assume a resting position
- Ice – apply an ice pack to the affected area
- Compression – use bandaging to hold the ice pack in place
- Elevate – keep the affected limb elevated
Maintain care until handover to appropriate practitioner.
Spinal Injury Management
The vertebrae (bones) of the spinal column protect your spinal cord located all the way up and down your back. If the mechanism of injury has or could have affected this area of the casualties body then we must take particular care to minimize the risk of damage or further damage to the spine. Depending on the section of spinal cord damage, the casualty could be left without control of movement from the hips (paraplegia) or neck (quadriplegia) down.
Following trauma should any of the following factors be present:
- dangerous mechanism of injury
- fall from a height of greater than 1 metre or 5 steps
- axial load to the head or base of the spine – for example diving, high-speed motor vehicle collision, rollover motor
- accident, ejection from a motor vehicle, accident involving motorised recreational vehicle, bicycle collision, horse riding
- accident, pedestrian v vehicle
- Impaired awareness (alcohol/drug intoxication, confused/uncooperative or Altered Levels of Consciousness)
- age 65 years or older
- age 2 years or younger incapable of verbal communication,
the patient should be regarded as ‘high risk’ and have active spinal motion restriction applied until assessment is complete.
Following trauma assessment are there:
- any significant distracting injuries
- impaired awareness (alcohol/drug intoxication, confused/uncooperative or ALoC)
- immediate onset of spinal/midline back pain
- hand or foot weakness (motor issue)
- altered or absent sensation in the hands or feet (sensory issue)
- priapism – persistent and painful erection of the penis.
- history of spinal problems, including previous spinal surgery or conditions that predispose to instability of the spine
- unable to actively rotate their neck 45 degrees to the left and right (P & AP only)
Advise patient to remain still until arrival of higher level of care
- Kneel/lie behind head
- Rest elbows on ground/knees
- Grasp side of head
- Spread fingers/don’t cover ears
- Steady/support head in neutral position
The Pre-Hospital Emergency Care Council have issued several further recommendations to help guide First Aid Responders in situations they may be providing assistance.
Uncooperative patients shall not be forced into active spinal motion restriction as this is a greater risk to the patient.
The aim of recommendation 5 is to ensure that additional unnecessary motion is not applied to a potentially unstable injury through forced spinal motion restriction.
While waiting for the arrival of a practitioner, responders shall provide active spinal motion restriction for all patients if ‘high risk’ or ‘low risk’ factors are present.
Responders at FAR/OFA level should maintain the patient with suspected spinal injury in the position found while
maintaining active spinal motion restriction.
The aim of recommendation 24 is to ensure that both ‘high risk’ and ‘low risk’ patients have minimised movement until a practitioner clinical assessment occurs.