8.1. GENERAL INJURY

Related titles

Absent.

The purpose of providing EMD

1. Operative assessment and elimination of life-threatening conditions.
2. Safe transfer of the patient in order to prevent deterioration of the lesion.
3. Quick and safe transportation to the appropriate medical facility.

Inclusion criteria

Patients of all ages with existing injuries due to mechanical trauma, including blunt trauma, penetrating trauma, burns.

Exclusion criteria

Absent.

Management of the patient

Status assessment

1. Primary review.

1.1. Bleeding control.
Assess for and stop any heavy bleeding (see Extremity Injury/External Bleeding Control).

1.2. Respiratory tract:

a) assess the patency of the airways during the interview of the patient, pay attention to the presence of stridor and free air movement;
b) examine for the presence of injuries that may lead to obstruction airway, including unstable facial fractures, enlarging neck hematoma, blood or vomitus in the airway, facial burns/inhalation injuries;
c) assess level of consciousness for ability to independently control airway patency: patients with a score 8 and less according to SHKG may require protection of the respiratory tract.

1.3. Breathing:

a) assess the frequency of breathing and available respiratory efforts;
b) assess the symmetry of chest movements;
c) assess the presence of chest breathing bilaterally.

p>

1.4. Circulation:

a) assess blood pressure and heart rate;
b) signs of hemorrhagic shock: tachycardia, hypotension, pale, cold and moist skin, capillary refill longer than 2 seconds.

1.5. Disturbance of consciousness:

a) assess the neurological status (see Appendix 3);
b) assess the general motility of the limbs;
c) assess the presence of clinical signs of brain injury :

• • • • sizes and reaction of the pupils;
      • lateral motor signs;
      • dystonia.

1.6. The influence of the external environment:

a) quick examination of the whole body, detection of possible penetrating wounds or other blunt injuries. It is necessary to wrap the patient in a thermal blanket and, if possible, examine the back;
b) prevent the occurrence of hypothermia.

Treatment and intervention

1. Bleeding control.
Stop massive bleeding (see “Injury of the limbs/External bleeding control” guideline).

2. Respiratory tract:

a) ensure patency, taking into account the possible injury of the cervical spine (according to the instructions “Airway control” and “Help with spinal trauma”);
b) in in case of inadequate breathing, ventilate with the help of an AMBU bag and apply air ducts. If the patient is not able to independently control the airway, use an oral airway (the nasal airway should not be used in case of facial trauma or a possible fracture of the skull base);
c) in case of increasing obstruction of the airways or impaired state of consciousness, which may be a threat of loss of independent airway patency control, provide full airway control according to available equipment and clinical experience.

3. Breathing:

a) in the absence or weakened breathing and hypotension, one should suspect the presence of a tense pneumothorax and perform needle decompression;
c) constantly monitor blood saturation and, if necessary, provide additional oxygen therapy.

4. Circulation.

4.1. If the pelvis is unstable and the patient is hypotensive, fix the pelvis with a special fixation belt or sheet.

4.2. Provide I/O access.

4.3. Infusion resuscitation.

a) adults:

• • • • with systolic pressure above 90 mmHg. infusion resuscitation is not required;
      • with systolic pressure below 90 mmHg. or HR greater than 120, administer infusion resuscitation and reassess the patient;
      • penetrating trauma: the goal of infusion resuscitation is to raise the systolic pressure to 90 mmHg. (or the appearance of a peripheral pulse);
      • head injury: systolic pressure 100-120 mmHg, avoid hypotension to maintain cerebral perfusion;

b) children:

• • • • if the child has tachycardia with signs of poor perfusion (low BP, capillary refill longer than 2 sec, altered consciousness, hypoxia, weak pulse, pallor, or moist/cool skin), administer 20 mL/kg crystalloid bolus and reassess ;
      • target normal blood pressure according to age (see Appendix 4).

5. Inability.
For clinical signs of TBI – see guideline “Head injury”.

6. Influence of environmental factors.
Prevent the occurrence of hypothermia:

a) remove wet clothes;
b) cover with a thermal blanket to prevent further heat loss.

7. Caution: Patients with massive bleeding, unstable hemodynamics, penetrating trunk trauma, or evidence of TBI usually require immediate surgical intervention. Minimize the time you stay at the scene (optimally – less than 10 minutes) and begin rapid transportation to a specialized medical facility.

8. Decisions regarding the appointment of transport should be based on the guideline “Field Triage of Injured Patients” (see Appendix 5).

Secondary assessment, treatment and intervention

1. Evaluation

1.1. Take a history (question the patient or family members) regarding:

a) allergies;
b) what medicines he takes;
c) previous history of diseases and operations;
d) preceding events trauma.

1.2. Secondary examination: physical examination from head to toe:

a) head:

• • • • examine the head for soft tissue injuries or bony crepitations;
      • evaluate the pupils;

b) neck:

• • • • evaluate the presence of: contusions, scratches, hematoma, tension of the jugular veins, deviations of the trachea;
      • evaluate the presence of crepitus;
      • evaluate the spine according to the guideline “Help for Spine Injury”;

c) chest:

• • • • palpate for instability/crepitation;
      • evaluate breath sounds;
      • assess for penetrating trauma or soft tissue damage;

d) belly:

• • • • evaluate sensitivity;
      • assess for penetrating trauma or soft tissue damage;

g) pelvis:

• • • • assess for penetrating trauma or soft tissue damage;
      • assess stability by pressing on the pelvic processes on both sides;

e) back:

• • • • maintain an even position of the spine, act according to the instruction “Help for spinal injuries”;
      • assess for penetrating trauma or soft tissue damage;

e) neurological examination (see Appendix 3):

• • • • serial assessment of the state of consciousness;
      • assessment of general motor and sensory function of all limbs;

is) limbs:

• • • • assess for fractures/deformation;
      • assess peripheral pulse/capillary filling.

1.3. Additional caveats:

a) maintain an even position of the spine according to the guideline “Help for Spinal Injury”;
b) apply a splint to obvious fractures according to the guideline “Extremity Injury/Control of External Bleeding” “;
c) provide analgesia according to the instruction “Pain control”.

Patient safety

1. Life-threatening injuries should be detected during the initial examination and should be quickly treated, as well as quickly hospitalized in a trauma department; secondary inspection is carried out during transportation.

2. Monitor for signs of deterioration by monitoring vital signs and repeat neurologic examination (see Appendix 3):

a) patients with compensatory shock may not show signs of hypotension until the moment of extensive blood loss;
b) the condition of patients with TBI may worsen due to intracranial edema and increased bleeding.

p>

3. Suspect the possible progression of worsening airway patency in head and neck injury.

Useful information for training

Key points

1. Optimal trauma care requires a structured approach using the ABCDE algorithm (Airway, Breathing, Circulation, Impairment, Environmental Exposure).
2. Minimize on-scene stay to 10 minutes or less in unstable patients or those potentially requiring surgery.
3. Training of an EMD specialist should include familiarization with the use of field instructions for the triage of injured patients.
4. It is important to re-examine:

a) if the patient develops worsening ventilation, re-evaluate the respiratory sounds for a sign of pneumothorax;
b) if external bleeding on the limbs is controlled with a pressure bandage or tourniquet, re-examine them for signs of continued bleeding;
c) in case of deterioration of consciousness, conduct a full examination and re-evaluate neurological status (see Appendix 3).

Traumatic cardiac arrest: Withholding and stopping resuscitation measures

Abstinence from resuscitation should occur in the presence of the following factors:

1. Decapitation.
2. Hemicorpectomy.
3. Presence of cadaveric rigidity or concomitant signs of death.
4. Blunt trauma: lack of breathing, pulse, organized cardiac activity on the monitor.

Caution – Children and Adults: CPR may be withheld in patients with cardiac arrest if there is no return of spontaneous circulation after 15-30 minutes of CPR, including airway control, assessment/ treatment of possible tension pneumothorax, liquid bolus with minimal interruptions during CPR.

Key elements of documentation

1. Mechanism of injury.
2. Primary and secondary review.
3. Sequential assessment of vital signs and neurological status.
4. Time spent at the scene.
5. Performed procedures and the patient’s response to them.

Criteria for the effectiveness of aid provision

1. Time of monitoring unstable patients at the scene.
2. Monitoring compliance with procedures.
3. Monitoring compliance of respiratory tract control methods.