Injuries

Trauma is the third leading cause of death in the United States, surpassed only by cardiovascular disease and cancer. In people under age 35, it's the leading cause of death.

There are three types of trauma:

• blunt trauma, which leaves the body surface intact
• penetrating trauma, which disrupts the body surface
• perforating trauma, which leaves entrance and exit wounds as an object passes through the body.

The basic elements of trauma care include triage; assessing and maintaining the patient's airway, breathing, and circulation; protecting the cervical spine; assessing the patient's level of consciousness (LOC); and preparing the patient for transport and surgery as necessary.

Combat shock

Because severe injuries commonly lead to shock, inspect the patient's skin for color and note skin temperature and moisture. Make sure he's receiving I.V. fluids (lactated Ringer's or normal saline solution), followed by blood or blood products, if warranted.

CULTURAL TIP Members of some religious groups, such as Jehovah's Witnesses, are opposed to the administration of blood and blood products. Some may be persuaded in emergencies to receive these products, but a court order may be needed if the situation is life-threatening and the patient (or parent of an injured child) still refuses.

In all cases of massive external or suspected internal bleeding, watch for hypovolemia and estimate the amount of blood lost. Remember that a blood loss of 500 to 1,000 ml might not change systolic blood pressure, but it might elevate the patient's pulse rate.

Stay alert for signs of occult bleeding, common in the chest, abdomen, and thigh. Assess for occult bleeding by taking serial girth measurements at these sites. Use a tape measure and mark where you placed it on the body with a marking pen so that you measure in exactly the same place each time. This way you can accurately detect any enlargement. Increased diameter of the abdomen, chest, or thigh typically means leakage of blood into these tissues. Such blood loss will induce classic signs of hypovolemic shock (tachycardia, tachypnea, hypotension, restlessness, decreased urine output, delayed capillary refill, and cold, clammy skin). 

Observe for faint, irregularly formed hemorrhagic patches on the skin around the umbilicus (Cullen's sign), which may signal retroperitoneal hematoma. Retroperitoneal bleeding may not cause abdominal tenderness.

If the patient shows clinical signs of hypovolemia, begin I.V. therapy immediately with two or more large­bore catheters, and regulate fluids according to the severity of hypovolemia. Assist with the insertion of a central venous pressure or pulmonary artery catheter to monitor circulating blood volume.

Splinting for transport

Look for limb fractures and dislocations, and check the patient's circulation and neurovascular status distal to the injury. Do this by palpating pulses distal to the injury and looking for the classic signs and symptoms of arterial insufficiency: decreased or absent pulse, pallor, paresthesia, pain, and paralysis. Splint the injury and apply traction, as needed.

Next, prepare the victim for transport. Use special care in suspected cervical spine injury. Splint the areas above and below the injury site to prevent further soft-tissue and neurovascular damage and to minimize pain. For instance, if the forearm is injured, splint the wrist and elbow, too.

In addition, ensure that family members or significant others are informed or updated about the patient's condition, permission forms are obtained as necessary, and emotional support is provided to the patient's family either by staff or clergy.

Types of splints

Types of splints include:

• soft splint- a nonrigid splint, such as a pillow or towels
• hard splint- a rigid splint with a firm surface, such as a long or short board, an aluminum ladder splint, and a cardboard splint
• air splint-an inflatable splint
• traction splint -a splint that uses traction to decrease angulation and reduce pain, such as a Hare or Thomas splint.

Tips for applying a splint

When splinting a patient's injury, keep in mind the following guidelines:

• Splint most injuries "as they lie," except when neurovascular status is compromised.
• Have one person support the injured part while another applies padding and the splint.
• Secure the splint with straps or gauze - not with an elastic bandage.
• To apply an air splint, slide the splint backward over your arm and grasp the distal portion of the injured extremity. Then slip the splint from your arm onto the patient's extremity and inflate the splint.

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