Non-Communicable Diseases, Emergency Care and Mental Health Module: 7. Injury-Related Emergencies and Supportive Care

Study Session 7  Injury-Related Emergencies and Supportive Care

Introduction

Emergency conditions are those that threaten a person’s life, limbs or eyesight. These are common conditions in every community all over the world. They can result in disability and death if they are not properly and urgently treated. Learning about these emergencies enables you to improve the outcome of life-supportive care, i.e. care that prevents death and reduces the risk of long-term disability in an individual who has suffered a life-threatening emergency. Note also that effective life-supportive care also protects the person’s family and his or her community from the socio-economic consequences of loss of life, limb or eyesight. These adverse outcomes reduce or destroy the productivity of the individual and affect their ability to care for their family and contribute to the community at large.

In this study session you will learn about common injury-related emergencies, how they occur, how to detect these conditions, and how to give basic life-supportive care to an injured person. You will also learn how to transfer a patient with these emergencies to a higher-level health facility for more complete specialist care. The emergencies to be covered in this session are acute injury and bleeding caused by violence, fractures, head and spinal injury, burns and multiple injuries.

Learning Outcomes for Study Session 7

When you have studied this session, you should be able to:

7.1  Define and use correctly all of the key words printed in bold. (SAQs 7.1, 7.2 and 7.4)

7.2  Describe how to stop external bleeding following an injury and how to assess a person for internal bleeding. (SAQs 7.1 and 7.4)

7.3  Identify different types of fractures and explain how to immobilise a fractured limb for transport to a health facility. (SAQs 7.1, 7.2 and 7.4)

7.4  Describe the signs and symptoms of head and spinal injuries and how to immobilise a person with such an injury for transport to a health facility. (SAQs 7.1, 7.2 and 7.4)

7.5  List the common causes and degrees of burns injuries and describe the first aid you should give for a burn. (SAQs 7.1 and 7.3)

7.1  Acute injury and violence

Acute injury refers to any physical damage to the body that occurs suddenly as a result of force. There are many ways in which a person can be injured, either unintentionally (for example, in an accidental fall or being hit by a vehicle), or intentionally through violence, war or attempted suicide. Figure 7.1 (on the next page) shows the distribution of deaths as a result of different types of injury worldwide.

Figure 7.1  Percentage of deaths worldwide due to intentional and accidental (unintentional) injuries among people aged 15–45 years. (Diagram: The Open University, Trauma, Repair and Recovery, SDK125, Case Study 6, Figure 1.3)

Violence includes rape and is the intentional and unlawful use of force between two individuals, or a group of people, leading to physical or mental harm. It is a major public health problem worldwide – each year more than two million people die as a result of injuries caused by violence. Many millions survive their injuries, but remain permanently disabled. Many other health problems result from violent assaults, including mental disorders (see Part 2 of this Module), sexually transmitted infections (STIs), unwanted pregnancies and behavioural problems.

7.2  Bleeding

Violence caused by blows, sharp objects, bullets or sticks, and other causes of acute injury like falling or road traffic accidents, usually results in bleeding – the loss of blood from the arteries, veins and capillaries in the cardiovascular system. (Look back at Figure 1.4 in Study Session 1 of this Module to remind yourself about these blood vessels.) Based on the source of bleeding, it can be classified into:

• arterial blood (bright red, foamy and spurting in pulses)
• venous blood (darker in colour and flowing swiftly from the wound)
• capillary bleeding (red, oozing slowly from the wound at a steady rate).

Life-threatening bleeding is called haemorrhage, but you should be aware that it could be due to external or internal bleeding. External bleeding is visible and obvious, whereas internal bleeding is hidden inside the body (abdomen, chest or a limb) and is more difficult to detect. We will describe the signs of each of them in turn, and how to give life-supportive care to a person who is bleeding.

7.2.1  External bleeding

External bleeding usually occurs following a deep cut, piercing with a sharp object or a superficial bullet wound. The most serious bleeding comes rapidly spurting from an artery. This can be life-threatening if the wound is too deep and the spurt is under too much pressure to control. Minor bleeding usually stops by itself within ten minutes when a blood clot develops which blocks the bleeding vessel or wound. You should suspect life-threatening external bleeding if:

• You see blood spurting from a wound
• Bleeding fails to stop after all measures to stop bleeding have been attempted (see Box 7.1)
• The person shows signs of excessive blood loss resulting in low circulating blood volume (shock).

7.2.2  Internal bleeding

This type of bleeding occurs when there is a rupture of arteries or veins inside the body, for example in the abdomen. It may be caused by a kick or violent blow, a fall or another type of accident. You should remember that even though the affected person does not show any sign of bleeding externally, there may be significant damage to the internal organs, usually to the liver, spleen or thigh bone (see Section 7.3.1 below), resulting in a large amount of hidden internal bleeding. The signs that should make you suspect internal bleeding are given in Box 7.2.

Measure the injured person’s blood pressure and pulse rate. If you suspect they have internal bleeding, lie the person down on their back. Raise their legs in an attempt to improve their blood pressure by allowing some blood from the legs to drain back towards the heart. Get someone to hold the person’s legs up for you, or use pillows to support them (Figure 7.2). Then secure an intravenous (IV) cannula in a vein in the person’s hand or arm and begin fluid infusion with a litre of Normal Saline or Ringer’s Lactate solution. Then transfer them urgently to the nearest health facility.

Figure 7.2  Raise the person’s legs to increase their blood pressure if you suspect internal bleeding.

Do not allow the person to eat or drink anything before or during the journey to a health centre or hospital. Their condition may require surgical treatment to stop the internal bleeding, and food or fluids inside the stomach can be vomited into the lungs during surgery.

7.3  Fractures

Another common consequence of accidents or violence is fracture of a bone. A fracture is where there is a break in a bone caused by a force applied to the body. The degree of damage depends on the magnitude of force applied and the strength of the bone. Fractures can happen as a result of minimal force if the bone is weak due to underlying disease (e.g. osteoporosis, or bone cancer). If you have not come across osteoporosis before, it means softening of the bones due to reduction in the concentration of calcium in the bone. This condition is more common in older persons and people who are not moving around because of other illnesses or disability.

Figure 7.3  Children and young men are more likely to take risks that lead to fractures and other injuries.

7.3.1  Types of fractures

Fractures can be classified according to the following criteria:

• Closed or open fractures, depending on the presence or absence of skin perforation. In an open fracture, part of the broken bone pushes out through the person’s muscles and skin at the site of the fracture; in a closed fracture, the broken end of the bone is not exposed to view.
• Simple or complicated fractures, depending on presence (complicated) or absence (simple) of damage to soft tissues (nerves, arteries, muscles) around the site of the fracture.

7.3.2  Symptoms and signs of fractures

A person who has fractured a bone will have great pain, tenderness and abnormal movement at the site of the fracture, loss of function of the affected limb, deformity (bending), swelling and bruising. They can also have external or internal bleeding, resulting in low blood pressure and fast pulse rate. If you encounter a person who has been involved in an accident or injury with any of the above symptoms and signs, you should consider the possibility of fracture.

7.3.3  Supportive care for a bone fracture

You have learnt that it is very important to give IV fluid to someone who has shock and low blood volume due to blood loss from an injury or other causes. The amount of blood lost in fractures depends on the type of bone affected and the severity of the fracture. The larger the size of bone fractured, you should expect more blood to be lost. The amount of internal bleeding following a fracture is estimated as:

• About 1.5 l (litres) of blood is lost following fracture of a single thigh bone
• About 1.0 l is lost following fracture of bones of the lower leg (calf).

You should also be aware that fracture of a relatively small bone may result in a much larger amount of bleeding if there is associated injury to a major blood vessel. Therefore, you should always check for signs of shock after a fracture and begin IV fluid infusion if the person’s blood pressure falls and the pulse rises. Also give the person two paracetamol tablets with a small cup of water to relieve the pain of the fracture.

The other important component of basic supportive care for a person with a fracture in a large bone (e.g. in the arm or leg) is to immobilise the injured limb before transporting the person to a health centre or hospital.

A fractured limb is immobilised by keeping it straight, using a rigid material called a splint, which you can make from anything like very strong cardboard, a plank of wood, or similar material. The splint should be as long as the whole arm or leg (not just the broken part) to stop movement in the joint above and below the fractured site. It is usually fixed behind the affected limb by wrapping soft cloths around the limb and the splint to bind them together (see Figure 7.5). This process is called splinting. Splinting prevents further damage, which may result in loss of the limb or disability at a later period.

Figure 7.5  A health worker applying a split to a fractured leg bone.

Once you have applied the splint and fixed it securely, the next step is to make sure that the person reaches a hospital or health centre in a splinted state in order not to aggravate the injury further. By doing this you ensure that the patient is treated in a more specialised and complete way, which helps reduce the risk of death or disability from fracture.

7.4  Head and spinal injury

Head, neck and spinal injuries account for about 50% of the deaths immediately following injury globally. Injury to the brain or the spinal cord (the part of the nervous system that extends from the brain down inside the vertebral column or backbone) can affect the person’s ability to breathe and lead to permanent paralysis.

7.4.1  Causes, signs and symptoms of head and spinal injuries

Head injuries usually occur from blows to the brain. Injuries to the head may include fracture of the bones of the face or the skull, swelling of the brain due to inflammation and fluid collecting inside the skull after a blow to the head, or cuts to the scalp and other soft tissues around the skull. Spinal injury is when the backbone and the nerve tissue inside the spine are injured.

Certain causes of injury should alert you to possible head and spinal damage. These include a fall from any height (e.g. from a horse, motorbike, bicycle, or building), a penetrating injury to the head from a gun or knife, a heavy blow to the head, or a traffic accident (Figure 7.6). When you are called to see a person after any of these events, you should suspect the possibility of head or spinal injuries. These accidents are also common to fracture injuries. The symptoms and signs of head injury or spinal injury are given in Box 7.3.

Figure 7.6  Accidents involving a bajaj (in Amharic, a three-wheeled taxi) often occur in heavy traffic. (Photo: Basiro Davey)

7.4.2  Emergency care for someone with a head or spinal injury

When you suspect an individual has a head or spinal injury, the first thing to make sure is whether the person’s airway is clear, so he or she is able to breathe. Then check for signs of blood loss and shock as described earlier. It is very important to keep the person at rest, not moving, and in the position you found him or her. When you approach the injured person, approach from the foot end, to reduce the risk of moving their head or neck and causing further damage.

After giving basic life-supportive care (described in the final section of Study Session 8), the next step is to prepare the injured person for transportation to a health facility. This primarily involves protecting and stabilising the spinal cord in the neck, so that it cannot move and cause more serious damage, which may lead to death or permanent disability. Apply sandbags or pillows on each side and at the back of the neck to immobilise the person’s head and neck (Figure 7.7).

Figure 7.7  Supporting and immobilising an injury to the neck or spinal cord. (Diagram: Dr Radmila Mileusnic)

7.5  Burns injuries

Burns are such a common accident that you are sure to have seen someone suffering from a burn in your village. A burn is a severe form of injury which causes significant soft tissue damage, as well as changes affecting blood volume (fluid balance). By fluid balance it is meant that people with a major burn will develop shock as a result of evaporation of body fluids from the burn surface; this reduces their blood volume even though they are not bleeding. While most burns are minor and do not require hospitalisation, extensive burns are a life-threatening emergency. You should also know that the very young and the very old do not tolerate burns well or respond so well to treatment (Figure 7.8).

Figure 7.8  A tragic situation when a farmer’s house catches fire and a child is burned.

7.5.1  Common causes of burns

What are the common causes of burns in your village? Do they include the situations listed in Box 7.4, which are common all over the world?

All these causes of burns result in destruction of the skin and varying layers of the soft tissue underneath. In burns injuries, the depth of the burn depends upon the temperature of the heat source and how long the body was in contact with it. The most common sites of a burn are the hands, arms, legs and feet.

Other important burns-related conditions that you should know about are burns involving the chest, face and inhalation (breathing in) of a large amount of smoke and heat. These conditions require urgent special attention at a health facility due to the risk that they will interfere with breathing. You should suspect a respiratory tract burn when the person inhales a large amount of smoke and heat as a result of being trapped in a closed space during a fire.

7.5.2  Classification of burns

Most burns injuries are minor and do not require hospitalisation. Factors that affect the severity of a burn include the age of the person, the presence of burns to the face or respiratory tract (lungs), and of course, the depth of the burn. Burns can be classified into first degree (superficial), second degree (intermediate), or third degree (full-thickness) depending on the depth of injury to the skin and underlying structures.

7.5.3  Emergency care for people with serious burns

If first aid has not already been given, flush the burn thoroughly with clean cold water. This helps to prevent further damage. You should also remove all burned clothing from the body of the person. If the burn area is limited, immerse the site in cold water for about 30 minutes. This again helps reduce pain, swelling (oedema) caused by tissue fluid flooding into the damaged area, and inflammation.

The other important aspect of immediate care in a major burn is prevention of heat loss from the body, especially in children, if a large area of the body has been burnt, or there are third degree burns. Hypothermia is defined as excessive cooling of a person or reduction of body temperature which, if not prevented, may result in the body systems stopping their normal function. To prevent hypothermia from happening you should apply clean wraps around the burnt area or the whole patient.

What you have studied so far is only the first aid treatment for a severe burn. Once you have done this, refer individuals with severe burns to a hospital or health centre for specialist care. This must be done as soon as possible. The first six hours following a burns injury are critical for recovery.

7.6  Multiple injuries, emergency transport and referral

In the previous sections of this study session, we have described how to treat bleeding, fractures, head and spinal injuries and burns when they occur separately. However, in many accidents or after a violent attack, the patient is often suffering the combined effects of multiple injuries – several injuries at the same time. Knowing that multiple injuries are likely to happen in the same individual helps you to remember that you must not concentrate only on one type of injury – you must focus on all the multiple effects and your first priority is to address whatever is most threatening to their life. Delivery of basic life-supportive care is taught at the end of Study Session 8, after you have learned about emergency conditions that are not due to injuries.

Remember that most health emergencies will require rapid referral to a health centre or hospital. As a Health Extension Practitioner, you have an important responsibility in your community to prepare an emergency transport plan, which identifies individuals with vehicles (car, truck, gharry, etc.) who can get injured people to a health facility as quickly as possible. As in all referrals for whatever cause, you must write a clear referral note, describing the patient’s name, address, age, etc., the circumstances in which the injury or other emergency occurred, your assessment of their condition and any actions you have taken.

Summary of Study Session 7

In Study Session 7, you have learned that:

1. Injury due to accidents and violence is a common cause of emergency conditions which threaten life, limb and eyesight; it is a common problem globally and at national level.
2. The effect of an injury is not limited to immediate life-threatening emergency conditions; it can persist way beyond the immediate injury period in the form of profound economic, mental health and behavioural problems.
3. Violent assaults such as rape can lead to sexually transmitted infections (STIs) and unwanted pregnancies
4. Injury often results in life-threatening internal or external bleeding. Try to stop external bleeding with pressure and bandages. Start pre-referral IV fluid therapy in cases of shock.
5. Fractures (open or closed), head and spinal injuries must be attended to urgently in order to prevent loss of limbs, paralysis and permanent disability. Immobilisation of the injured part during transport to a health facility is essential life-supportive care.
6. Flame, hot fluid, chemicals and electricity are the common causes of first, second or third degree burns, depending on the depth of skin and soft tissue affected. Flushing a burn with cold water is an important element of first aid care in order to minimise the extent of damage and reduce pain.
7. Remember to develop an emergency transport plan to get an injured person to a health centre or hospital quickly. Write a clear referral note with all the patient’s details, your assessment of the injury and any actions you have taken.

Self-Assessment Questions (SAQs) for Study Session 7

Now that you have completed this session, you can assess how well you have achieved its Learning Outcomes by answering these questions. Write your answers in your Study Diary and discuss them with your Tutor at the next Study Support Meeting. You can check your answers with the Notes on the Self-Assessment Questions at the end of this Module.

Read Case Study 7.1 about Mr. Samuel and respond to the question that follows it.

Case Study 7.1  Mr. Samuel has a horse-riding accident

Mr Samuel is a 54-year-old farmer who was heading home from his farm (Figure 7.9). He was riding fast when his horse stumbled and fell into a ditch, throwing Mr Samuel against a rock on the ground. He was found by some villagers, who called you to see him. When you reach the place, you see that he is lying on the ground and he seems unable to get up. You can’t see any blood on his clothes.

Figure 7.9  Falling from a horse can cause serious injuries. (Photo: Basiro Davey)