T14.0-1/T14.9
DESCRIPTION
Injuries may be minor, moderate or major:
Major injuries: it is important is to recognise potentially life-threatening injuries. Indicators of such injuries are:
- Mechanism of injury: motor vehicle collision at speed exceeding 60 km/hour, ejection from the car, death of other occupant in the same car compartment, roll-over, pedestrian thrown out of his/her shoes, fall from height of more than 2 stories (more than thrice the patient’s height in a child), multiple gunshot wounds.
- Physiological status: unable to maintain airway, tachycardia, hypoxia, hypotension on arrival (even if corrected with crystalloid infusion), tachycardia (especially in a child) or decreased level of consciousness.
- Anatomical distribution: (suspicion of) injuries to more than one body region (face, intracranial, chest, abdominal cavity, spine).
- Age: children < 2 years of age require admission.
Moderate injuries (list is not exhaustive):
- Head injuries: moderate head injuries (i.e. any GCS 11-14), facial fractures (airway maintained).
- Neck injuries: stable patient with a stabbed neck, tenderness over C-spine.
- Chest injuries: pneumothorax, haemothorax, rib fractures (2 or less).
- Abdominal injuries: any suspicion of an intra-abdominal injury in a haemodynamically stable patient: e.g. abdominal bruising (including seat belt sign in children), tenderness, distension, loss of bowel sounds, vomiting, haematemesis or haematuria.
- Extremity injuries: major open wounds, degloving injuries (boggy feel under intact skin), fractures, dislocations (in children: point tenderness around a major joint), crush injuries, multiple soft tissue injuries, enlarging or pulsating swelling.
- Suspicion of abuse (child abuse, intimate partner abuse, elderly abuse).
Minor injuries are injuries that can be managed as an outpatient and include bruises, small lacerations, sprains, concussions etc.
- Human bites (see Human bites) and animal bites (see Animal bites).
- Sprains or strains (see Sprains and strains).
- Exclude fractures.
EMERGENCY MANAGEMENT
All trauma patients, except for those who only have minor injuries, should undergo these surveys:
Primary survey
A = Airway: check and maintain airway. If airway obstructed, first perform a jaw thrust manoeuver, then if able, insert an endotracheal tube. Patients with maxillofacial fractures may require a tracheostomy.
B = Breathing: assess respiratory rate, use of accessory muscles, symmetry, oxygen saturation. If needed, support breathing using a Bag-Valve-Mask device (‘AMBU bag’). Look for signs of pneumothorax (affected site is hyperinflated, hypertympanic and has decreased breath sounds). If tension pneumothorax (distended neck veins, deviated trachea, hypoxia and hypotension): perform a needle thoracostomy.
C = Circulation: look for tachycardia and hypotension. Put up two large bore peripheral lines, a femoral line or an intraosseous line in the tibia (if no abdominal injury) or the proximal humerus. In adults: if SBP if < 90 mmHg, infuse 2 L of sodium chloride 0.9% until SBP ≥ 90 mmHg. If actively bleeding, it is permissible to maintain SBP≥ 80 mmHg (or a palpable radial pulse if you do not have access to a BP machine). In children the SBP should not fall below (70 + [2 x age]) mmHg.
D = Disability: perform a brief neurologic assessment and classify according to the Glasgow Coma Score:
| Best motor response: | Obeys commands | 6 |
| Localises to pain | 5 | |
| Withdraws from pain | 4 | |
| Abnormal flexion to pain | 3 | |
| Extends to pain | 2 | |
| None | 1 | |
| Best verbal response: | Orientated | 5 |
| Confused | 4 | |
| Inappropriate words | 3 | |
| Incomprehensible sounds | 2 | |
| None | 1 | |
| Eye opening | Spontaneous | 4 |
| To voice | 3 | |
| To pain | 2 | |
| None | 1 | |
| Total |
E= Exposure/environment: expose the patient. If any suspicion of spinal cord injury (multi-trauma, decreased level of consciousness, neurological deficit, tenderness over the spine, severe mechanism of injury, anatomic deformity of the spine or any of the following: intoxication, inability to communicate or a distracting injury) cut the patient’s clothes off, so as to minimise movement of the spine, and immobilise neck using a long back board. Use a hard collar and strapping to the trolley in other patients Prevent hypothermia by covering the patient with warm blankets, and infusing warm fluids.
When major physiological derangements have been identified and the patient is stabilised using the ABCDEs of the primary survey, perform an AMPLE history and a secondary survey:
AMPLE history:
A = allergies
M = the patient’s regular medication (including contraceptives and OTC medication)
P = past medical history
L = time of last meal (particularly important is the time between the last meal and the accident)
E = Events leading up to the incident
Secondary survey
The secondary survey is a head-to-toe examination of the patient to identify any injuries that may have been missed during the primary survey. The secondary survey is only performed in a stable patient.
First examine patient from the front, then log-roll the patient and examine the back (include a rectal examination).
All fracture sites must be immobilised by external splints.
Finally, any additional investigations are ordered according to availability of resources:
- Bloods may include FBC, clotting profile, cross-match and U & E’s.
- Consider whether the patient requires transfer for x-rays.
MANAGEMENT OF WOUNDS AND LACERATIONS
- Assess wound: if significant devitalised tissue, especially if due to a crush injury or a bite, dress with povidone-iodine and refer for surgical debridement.
- Assess surrounding tissues and test function: look for associated fractures, ligament/tendon damage and nerve or vascular injuries. Document.
- If needed, anaesthetise wound. Remove foreign bodies and irrigate the wound with sodium chloride 0.9%. If needed, remove any devitalised tissue with a knife
- Wounds may be glued with tissue adhesives if wound < 4 cm, clean and uncomplicated, especially in children and elderly patients. Avoid in the following cases: lacerations in areas under tension (hands, feet, joints), oral mucosa, wounds in moist or hairy areas (axillae/perineum), if needing high level of precision (hairline or vermilion border of lip), wounds at increased risk of infection (bite wounds, puncture wounds, wounds with contaminated tissue). Wounds on the scalp can be glued but surrounding hair needs to be trimmed.
Tissue adhesive (glue):
- Clean wound thoroughly with chlorhexidine 0.05% aqueous solution.
- Ensure good haemostasis before applying glue.
- Appose wound edges (bring wound edges together). Ensure patient positioned appropriately so that when applied, any excess glue does not run down into areas not meant to be glued. If this happens, quickly wipe away with dry gauze.
- Crush tissues adhesive vial and invert.
- Gently brush adhesive over laceration (avoid contact with gloves/ instruments and avoid pushing adhesive into wound).
- Apply three layers of adhesive (maximum bonding strength is achieved within 2.5 minutes of application).
- Do not put on any covering or dressings.
- Advise patients that they may shower but not soak in bath and to pat area dry. -
- The bonded adhesives spontaneously slough off within 5 to 10 days.
MEDICINE TREATMENT
If fluid replacement needed, see Shock .
Adults
- Sodium chloride 0.9%, IV, 1L as a rapid bolus.
- Repeat bolus until blood pressure is improved.
Children
- Sodium chloride 0.9%, IV, 20 mL/kg as a rapid bolus.
- Repeat bolus if no adequate response.
Note: If patient develops respiratory distress, discontinue fluids.
Tetanus prophylaxis: Z23.5
If not previously immunised within the last 5 years
- Tetanus toxoid (TT), IM, 0.5 mL.
If sutures needed:
- Lidocaine without adrenaline (epinephrine), injection.
- Infiltrate 7 mg/kg, around the wound as local anaesthetic
- Maximum dose: 3 mg/kg.
|
Weight kg |
Maximum dose, mg |
Vial 1%, 10 mg/mL |
Vial 2%, 20 mg/mL |
Age months/years |
| ˃2.5–3.5 kg | 7 mg | 0.7 mL | 0.35 mL | Birth–1 month |
| ˃3.5–5 kg | 10 mg | 1 mL | 0.5 mL | ˃1–3 months |
| ˃5–7 kg | 15 mg | 1.5 mL | 0.75 mL | ˃3–6 months |
| ˃7–9 kg | 20 mg | 2 mL | 1 mL | ˃6–12 months |
| ˃9–11 kg | 25 mg | 2.5 mL | 1.25 mL | ˃12–18 months |
| ˃11–14 kg | 30 mg | 3 mL | 1.5 mL | ˃18 months–3 years |
| ˃14–17.5 kg | 40 mg | 4 mL | 2 mL | >3–5 years |
| ˃17.5–35 kg | 50 mg | 5 mL | 2.5 mL | >5–11 years |
| ˃35–55 kg | 100 mg | 10 mL | 5 mL | >11–15 years |
For children > 55 kg and adults:
- Lidocaine without adrenaline (epinephrine), injection.
- Infiltrate around the wound as local anaesthetic.
- Maximum dose: 3 mg/kg.
Pain:
Children
- Paracetamol, oral, 10–15 mg/kg/dose 6 hourly when required. See See paediatric dosing tool.
Adults
- Paracetamol, oral, 1 g 4–6 hourly when required.
- Maximum dose: 15 mg/kg/dose.
- Maximum dose: 4 g in 24 hours.
For more severe pain, give analgesia as appropriate. See See paediatric dosing tool.
Infected wound management:
Manage as for cellulitis. See Cellulitis.
REFERRAL
Urgent
- All major and moderate injuries once stabilised.
- Infected wounds.
Note:
- If uncertain how to stabilize patient, phone for guidance from referral hospital.
- Before transport leaves, ensure endotracheal tube is securely strapped, all lines are secured, all drips are running well and patient is well covered to prevent hypothermia.
- If transport delayed, ensure patient does not deteriorate while waiting: repeat ABCD survey at least hourly.