50. Introduction
From Primary Surgery
Contents |
50.1 A system of traumatology
Trauma is universal and the care of the common injuries is an essential part of Primary Care.
1. This book Primary Surgery Volume II describes the treatment of trauma so as to prevent death and disability. For every patient who dies from trauma, at least two are permanently disabled.
2. Many of those who suffer from trauma are in the most productive period of their lives.
3. Patients die at various intervals after injury:
(a) Patients who die immediately, within minutes, from lacerations of the brain, brain stem’, or spinal cord. Most of these patients present at the mortuary, and account for about half of those who eventually die. There is little you can do for patients in this group.
(b) Patients who die within a few hours of the accident from bleeding into the skull, thorax, or abdomen, or from multiple lesser injuries. This group is your main challenge. These patients can usually be saved using quite simple technology—if you apply it within four hours of injury. But rapid transport and surgical intervention are required.
(c) Patients who die days or weeks later from infection or multiple organ failure.
(2) Some patients who need admitting to hospital, but are in no danger of death. You will probably find that about half
the beds in your hospital will be surgical and about half the patients in them will have been injured.
(3) Some patients with quite severe injuries whom you can treat as out–patients.
(4) Very many patients with only minor injuries. Although the injuries may look trivial, many of these patients are wage earners and want to be back at work quickly. If you don’t treat them carefully, complications may keep them away from work for weeks.
We have classified the methods of treatment that injured patients need into the three levels shown in Fig. 50-1. Like most classifications it is only a working compromise.
Level One, the care of a severely injured patient as a whole. When you first see a severely injured patient start with Section 51.3 and approach him systematically.
Level Two, the general methods. Some of these apply anywhere in the body and are those for shock (53.2), burns (58.1), split skin grafting (57.5), plastercraft (70.6), skin traction traction (70.10), skeletal traction (70.11), and amputations (56.1). Other general methods, such as opening and closing the abdomen, and making a colostomy, are described in Book One.
The general methods for particular regions of the body are those for injuries of a patient’s eyes (60.1), his face (61.1), his maxillofacial region (62.1), his lower jaw (62.7), his head (63.1), his spine (64.1), his chest (65.1), his abdomen (66.1), his lower urinary tract (68.1), and his hands (75.1).
Level Three, specific methods and specific injuries, form most of the book, and assume a knowledge of the methods in Level Two. For example, the methods for each particular amputation describe only the details peculiar to each site, and assume that you know the general method.
If a patient is seriously ill with many injuries, you may need to work through all three levels. But if he only has a minor injury, such as a subungual haematoma (75.5), you can work at Level Three only. You are unlikely to forget Level One, but you may forget to refer to the general methods in Level Two. For example, don’t treat a severe finger injury without following the ‘General method for a hand injury’ (75.1).
USE THE METHODS AT ALL THREE LEVELS
After first aid at the scene of the accident, we describe the care of an injured patient as a whole, the care of his airway, and the management of shock. Then come wounds, and with them artery, nerve, and tendon injuries. This is followed by methods for skin grafting and for the burns they are mostly used to treat.
After a brief discussion of radiation injuries, the rest of the book is arranged anatomically, starting at a patient’s head and working down his trunk. Then come general methods for his limbs (plaster, traction, and amputations), followed by specific injuries of his arms and then his legs, the more proximal ones first.
| DIDIER (34) said that he had been hit on the scrotum by a bag of coffee. His scrotum was large and swollen and a quantity of bloody
fluid was aspirated from it. Two days later he started vomiting and complained of abdominal pain. He had not passed flatus or a stool since admission. A strangulated inguinal herniawas diagnosed and 50 cm of necrotic gut was removed at laparotomy, after which he recovered uneventfully. LESSON patients quite often ascribe the onset of their condition to some quite coincidental trauma. |
50.2 Preventing trauma
Trauma—the tearing apart, burning, crushing, maiming,
lacerating, and irradiating of the human frame is potentially
one of the most preventable of mankind’s afflictions. Injuries
are the result of accidents or of violence, either personal,
communal, or international. Almost all of them could
be prevented, so what we say now about the absolute importance
of prevention, applies to all injuries in later pages.
Common prudence would prevent most of the injuries described here.
Road accidents are a major cause of death and disability in the developing world, so that measures to prevent them are urgent. Among other things, this means: (1) Seat belts for all front and, if possible, back seat passengers also. (2) The absolute rule that nobody should ever drive after having taken any alcohol whatsoever, not even a single drink. (3) The strict enforcement of traffic regulations and the separation, where possible, of motorized traffic from pedestrians. (4) In many developing countries better driving instruction andmore strictly examined driving tests are an urgent need.
Most of us are much more likely to die early from trauma than from anything else, so the personal precautions in this list apply particularly to ourselves.
Accidents with agricultural machines are often gravely mutilating, especially in rural communities using such machines for the first time. Proper precautions would prevent many injuries, so would elementary preventive measures in factories. Very often the same hazard causes the same injury in a succession of patients, so always ask how an injury was caused. If it was caused by something that might injure someone else, do your best to see that the danger is removed.
Many injuries, particularly burns to children, happen at home, and these too can be prevented by simple precautions. In many societies social disintegration is causing increasing violence. As the result, many of the injuries you see will be due to fists, teeth, bottles, knives, sticks, and bullets, many of them inflicted under the influence of drink.
No form of trauma is in such desperate need of prevention as the ’megatrauma’ from a nuclear holocaust. Many thoughtful people are now asking not if it will occur, but when it will occur. Preventing it is so important that it is considered separately in Chapter 59.
50.3 At the scene of the accident
A severe accident kills some patients instantly. Other patients
die shortly afterwards from causes that could have
been prevented, if they had been properly treated immediately
after the accident. It is the purpose of first aid to prevent
this unnecessary death and disability before the patient
ever reaches hospital. The first people to help are usually the
public passing by, so that the average knowledge of first aid
in the community as a whole should be high. Try to do all
you can to increase it, and particularly to teach the police
first aid.
If possible, send a nurse or medical assistant with the ambulance. You will probably be unable to keep one on permanent standby, so put your most intelligent and interested driver in charge of the ambulance and teach him the first aid described below. Interest him by letting him see how you care for injured patients in the theatre. His tasks include the care of a patient’s airway, and transport in the recovery position. An ambulance driver should also be able to immobilize the joints on either side of a fracture until a patient reaches hospital, so as to minimize pain, bleeding, shock, and further damage to the tissues.
THE MINIMUM REQUIREMENTS FOR AN AMBULANCE
THE AMBULANCE BOX
The contents of this should include a self inflating (AMBU) bag, face masks, oral airways, firm pads of sterile dressings, slings, crepe bandages, a headboard, a sucker, and Thomas splints or padded fracture boards. Pillows are also useful for splinting.
If you can send a suitably competent nurse or medical assistant with the ambulance, include bottles of a plasma expander or 0.9% saline, drip sets, and intravenous cannulae.
If you are called to the scene of an accident yourself, take a laryngoscope, an intubation set, a self-inflating bag, and a non-rebreathing valve.
IF YOU ARE FIRST AT THE SCENE OF AN ACCIDENT,
you may be in command, so your first duty is to supervise. Warn other traffic by displaying a red triangle, or hazard warning lights, or other lights, or by any other means. Extinguish lighted cigarettes or other fire hazards and ask drivers to switch off their engines. Get uninjured people out of vehicles onto a place of safety, then remove the casualties.
THE MINIMUM FIRST AID
Here are some of the things to teach your ambulance driver. He should be able to: (1) Clear the patient’s airway by holding his jaw forward and removing blood, vomit, and foreign bodies from his mouth. (2) Insert an oropharyngeal airway. (3) Use a sucker. (4) Place the patient in the recovery position for transport back to hospital. Not doing this is a common critical mistake. (5) Lift and carry a patient appropriately, particularly if he is suspected of having a spinal injury, as in Fig. 64-4. (6) Fit a temporary cervical collar. (7) Control bleeding by raising a wounded limb, by applying local pressure to a wound, and by pressing on the pressure points. (8) Ventilate a patient with a self-inflating bag. (9) Close an open chest wound. (10) Give external cardiac massage and mouth-to-mouth ventilation. (11) Treat shock by putting a patient into the legs-up position.
CAUTION ! (1) Transporting an unconscious accident victim on his back without proper attention to his airway is a major cause of unnecessary death. (2) The use of a tourniquet (55.1) is likely to do more harm than good.
FIRST AID FOR FRACTURES
Spine
Move the patient with great care as in Section 64.3. If necessary, move him on a board or a door, or strap him to a plank.
Pelvis
Tie three triangular bandages firmly round the patient’s pelvis, put pads between his legs and tie them together.
Arm
(1) Put his arm in a sling and bandage it firmly to his body. Or, (2) tie his arm to a splint which reaches to his axilla.
Fractures above the knee
Put the patient’s leg in a well padded Thomas splint. Take especial care to pad the neck of his fibula to prevent paralysis of his common peroneal nerve. If necessary, pad his leg well and hold it in place in a Thomas splint with a few plaster bandages.
Lower leg fractures
If no Thomas splint is available, pad a piece of wood or bamboo, or even a palm branch, and tie this to the patient’s injured leg, or bandage his injured leg to his normal one.
Other sections describe the first aid for obstruction of a patient’s upper airway (52.1), burns (58.1), tension pneumothorax (65.5), and flail chest (65.6).
