First step in first aid: stopping bleeding
Limb injuries: not only do tourniquets not work, but they can also cause reperfusion syndrome and aggravate the primary injury. It is worth recommending compression bandaging, but this is not a foolproof solution: for severe bleeding caused by high-energy penetrating and truncating injuries, it should be controlled by subfascial filling with gauze blocks and compression bandaging at the proximal supply artery and throughout the injured limb.
Thoracic injuries: bleeding from the arteries in the chest wall is the most common. Placement of chest drains, intermittent suction and effective analgesia (often intravenous ketamine) may help with pulmonary resuscitation and hemostasis.
Abdominal injury: If fluid resuscitation does not maintain a systolic pressure of 80 to 90 mmHg, an open laparotomy for damage control should be performed as soon as possible: intra-abdominal bleeding should be occluded with shabu and then the midline abdominal incision should be temporarily clamped shut with hemostatic forceps within 30 minutes. Minimally invasive laparotomy is not a surgical procedure, but a resuscitative measure that should be performed strictly by highly qualified physicians and nurses under ketamine anesthesia. This technique requires close knowledge of the indications before implementation and, if used appropriately, can be life-saving.
First aid step 2: volume resuscitation, warming and analgesia
Insulation should be observed during volumetric resuscitation: physiological coagulation is at its best at a body temperature of 38.5°C. When the central body temperature is below 35°C, it becomes very difficult to stop bleeding. Hypothermia is common in injured patients when resuscitation is performed in an outdoor environment for long periods of time, even in a tropical environment. It is easy to cool the patient, but difficult to rewarm him, thus preventing hypothermia is important. All fluids for oral and intravenous use should be maintained at 40°C to 42°C. Using room temperature fluids means cooling!
Hypotensive fluid resuscitation: If the patient’s hemostasis is not clear, fluid volume should be controlled to maintain systolic blood pressure at 80 to 90 mmHg .
Loss of colloid D supplementation with crystals: A number of recent controlled clinical studies have shown a slight negative effect of colloid fluids compared to crystalloid fluids in the treatment of hemorrhagic shock.
Oral fluid resuscitation is safer and more effective in patients with non-abdominal injuries where a gag reflex is present. Oral fluids should be low-sugar, low-salt fluids. Hypertonic fluids can cause an increase in plasma osmolality and exceed the osmolality of the intestinal mucosa, which can easily produce negative effects. Dilute rice gruel contains less food components and is recommended.
Analgesic drug of choice: repeated sedation of 0.2 mg/kg ketamine, which has a positive inotropic effect but does not affect the gag reflex, is especially indicated when transporting critically ill patients.
The third step of first aid: further examination
Further examination should be considered only when the condition is basically stable. If the condition worsens, primary care should be performed again immediately (repeat ABCDE). All procedures should be documented.
The whole body examination mainly includes
1.Cephalic examination
Scalp and eye abnormalities, external ear and tympanic membrane examination, and periorbital soft tissue injury level examination.
2.Neck examination
Penetrating injury, subcutaneous emphysema, tracheal displacement, jugular vein filling.
3.Neurological functional examination
Brain function examination using Glasgow coma score, spinal cord motor function, sensory and reflex function.
4.Thoracic examination
Clavicle and all ribs, breath sounds and heart sounds, electrocardiogram monitoring (if available).
5.Abdominal examination
Most penetrating abdominal injuries require surgical exploration, blunt contusions require insertion of a nasogastric tube (except for compound facial injuries), rectal examination, insertion of a urinary catheter (the urethra should be checked for bleeding before insertion)
6.Pelvic and limb examination
Fractures, terminal arterial pulsations, knife cuts, contusions and other minor injuries
7.X-ray examination (if possible or indicated)
X-ray of the thoracic and cervical spine (it is important to show clearly all 7 cervical vertebrae)
X-ray of the pelvis and long bones
When head injury is present without focal neurological deficits, a cranial x-ray is useful to diagnose the presence of skull fractures
Other optional examinations are available. Chest and pelvic X-rays may be required for initial treatment.
(i) Thoracic trauma
About 1/4 of trauma deaths are attributable to chest injury. Immediate death is primarily due to rupture of the heart and great vessels. Early death from chest injury is most often due to airway obstruction, pericardial tamponade, or aspiration.
Most patients with chest injuries require only simple management and do not require surgical treatment.
Respiratory distress is seen in: rib fractures/shackle chest, pneumothorax, tension pneumothorax, hemothorax, pulmonary contusions, open pneumothorax, aspiration
Hemorrhagic shock is seen in: hemothorax, mediastinal hematoma
Rib fracture: The fractured rib is mostly in the area of the affected lung and may cause pulmonary contusion or lung rupture. In elderly patients, a minor injury can result in a rib fracture. It usually takes 10 days to two weeks for the ribs to stabilize. Rib healing with scab formation is not seen until approximately 6 weeks later.
Hypertelorism: The unstable chest wall is free to move during a respiratory cycle and has paradoxical movements. It often causes severe respiratory distress.
Tension pneumothorax: Tension pneumothorax is formed when air enters the pleural cavity but cannot be expelled. The result is a progressive increase in intrathoracic pressure on the affected side, causing mediastinal displacement. The patient presents with shortness of breath and hypoxia. Emergency decompression with a thick needle is required before inserting an intercostal closed drainage tube. High-pressure air can deviate the trachea from the midline and, later, displace it.
Hemothorax: Most often seen in penetrating chest injuries, hypovolemic shock can occur if there is excessive bleeding, with the possibility of respiratory distress syndrome due to compression of the affected lung. The best treatment is to place a thicker chest drain.
A hemothorax with a bleeding volume of 500-1500 ml that stops after insertion of a chest drain can be treated with this closed drainage method alone.
After insertion of a chest drain, hemothorax with bleeding volume greater than 1500~2000ml or still active bleeding and bleeding volume of 200~300ml/h is an indication for further treatment: such as open-heart surgery.
Pulmonary contusion: Most often seen in chest injuries, which are likely to endanger the patient’s life. Pulmonary contusions may occur in high-speed accidents, such as fall from height and high-velocity ballistic injuries. The signs and symptoms include.
Shortness of breath (shortness of breath), hypoxemia, tachycardia, diminished or absent breath sounds, rib fractures, cyanosis.
Open thoracic trauma: Pulmonary atrophy and mediastinal displacement to the healthy side may occur due to exposure of the affected lung to the atmosphere. Treatment must be rapid. Attempts must be made to plug the chest wall breach, such as using plastic bags, until arrival at the hospital. Intercostal drainage, tracheal intubation and positive pressure ventilation are required in severe cases.
The following types of injuries are possible complications of trauma and have a high mortality rate even in regional central hospitals
Myocardial contusions: In some patients with blunt thoracic contusions associated with sternal or rib fractures, they are often complicated by blunt myocardial contusions. Its common manifestations include abnormal electrocardiogram and elevated cardiac enzyme profile. The symptoms need to be differentiated from myocardial infarction. If available, electrocardiographic monitoring should be given. The incidence of this injury is higher than we would expect and may become a cause of sudden death later in life.
Pericardial tamponade: Penetrating cardiac injuries are a leading cause of sudden death in urban areas. Blunt cardiac contusions are rarely associated with pericardial tamponade. If pericardial tamponade is suspected, pericardiocentesis should be performed as soon as possible. Common symptoms are as follows.
Shock, venous rage, cold and clammy extremities but no pneumothorax, and absent heart sounds. Pericardiocentesis is the first treatment measure.
Thoracic macrovascular injury: Injury to the pulmonary veins and pulmonary arteries is often fatal and is one of the leading causes of immediate death.
Tracheal or main bronchial rupture: is a more serious trauma with a mortality rate of at least 50%. The vast majority (80%) of bronchial ruptures are within 2.5 cm below the bulge. Common symptoms are as follows.
hemoptysis, dyspnea, subcutaneous and mediastinal emphysema, and occasionally cyanosis
Esophageal injury: Rarely in patients with blunt contusions, commonly in patients with esophageal perforation. If complicated by mediastinal inflammation and not detected in time, it is often fatal. Patients usually complain of sudden sharp-like pain in the upper abdomen and chest that radiates to the back. There may be dyspnea, cyanosis, and shock, but these tend to occur in the late stages.
Diaphragmatic injury: Commonly seen in blunt contusions of the chest, mostly in car accidents. It is often missed and not easily detected. Therefore, diaphragmatic injury should be suspected in all penetrating chest injuries.
Penetrating injuries are below the fourth anterior intercostal space anteriorly, the sixth lateral intercostal space laterally, and the eighth dorsal intercostal space, more often on the left side.
Thoracic aortic dissection: Most often occurs in patients with severe deceleration injuries, such as traffic accident injuries or fall from height injuries. Because the normal cardiac output is about 5 L/min, and the total blood volume in adults is only about 5 L, the mortality rate of aortic dissection is high.
Abdominal injury
Multiple injuries are often combined with abdominal injuries. The most commonly injured organ in penetrating injuries is the liver, while the spleen is most likely to be torn in blunt contusion injuries.
(ii) Abdominal trauma.
There are basically two types of abdominal injuries.
Penetrating wounds: (surgical treatment is very important) gunshot wounds, stab wounds;
Non-penetrating injuries: crush injuries, stub wounds, ligature injuries, acceleration or deceleration injuries
Approximately 20% of trauma patients have acute intra-abdominal hemorrhage and no signs of peritoneal irritation on initial examination, so repeated basic examinations are essential.
Stonecold injuries are difficult to assess, especially in unconscious patients, and may require abdominal irrigation. If an abdominal injury is to be ruled out, a dissection may be the best means.
A thorough abdominal physical examination should also include a rectal examination to assess: sphincter function, integrity of the rectal wall, presence of rectal bleeding, condition of the prostate, and attention to checking for bleeding from the urethra.
Female patients should be careful to exclude pregnancy, as the fetus can be salvaged. However, the best measure to save the fetus is to resuscitate and resuscitate the mother. However, a woman with a full-term pregnancy can be appropriately resuscitated only when the fetus is delivered. The degree of difficulty should be assessed at this time.
Diagnostic abdominal irrigation: it may be useful to determine whether there is a collection of blood or leaky intestinal fluid in the abdominal cavity. The results are highly instructive and can be an important diagnostic tool. If doubts remain, dissection remains the best diagnostic tool.
Indications for abdominal irrigation include: unexplained abdominal pain, lower chest injury, hypotension, unexplained decrease in hematocrit, abdominal injury with psychiatric abnormalities (alcoholism, brain injury), concurrent abdominal injury and spinal cord injury, and pelvic fracture.
Relative contraindications to diagnostic laparotomy are: pregnancy, history of previous abdominal surgery, inexperience of the operator, and results that are unlikely to change your management plan.
Indications for cesarean exploration.
① Significant signs of peritonitis on abdominal examination;
(ii) gradual decrease and disappearance of bowel sounds or significant abdominal distension;
③ free gas under the diaphragm;
④ abdominal puncture aspiration of gas, non-coagulated blood, bile or gastrointestinal contents;
⑤ bleeding in the stomach and intestines or a large amount of blood from the stomach tube;
⑥open wound with blood, intestinal contents, bile outflow.
Other special features regarding abdominal injuries.
Pelvic fracture: mostly complicated by hemorrhage and urinary tract injury
Rectal examination should be done to understand the condition of the prostate and whether there is bleeding in the rectum, and whether there are lacerations in the rectum and perineum.