PRIMARY TRAUMA CARE

Dr. Rebecca Jacob

Department of Anaesthesia

Dr. Vinod Shah

Department of Distance Education

CHRISTIAN MEDICAL COLLEGE, VELLORE.

Distance Learning Editor: Isobel S

Integrated Post Graduate Diploma in Family Medicine – 2012-13

Towards multicompetence in Secondary Level Care

 ACKNOWLEDGEMENTS

The distance learning course of the Integrated Post Graduate Diploma in

Family Medicine consists of 13 module booklets. The modules were prepared
by CMC faculty and doctors from mission hospitals who were trained in
distance learning methodology. The modules have been revised to meet the
requirements of this course from the distance learning materials prepared for
the erstwhile Fellowship in Secondary Hospital Medicine (under the
Department of Medicine Unit 1, CMC Vellore) and for the Post Graduate
Diploma in Family Medicine (under the Department of Distance Education,
CMC Vellore).

This module was prepared by Dr Rebecca Jacob, Department of Anaesthesia,

CMC Vellore. New activities and readings relating to Head injury (Activities
4.1-6, 4.1-7) and Burns management (Activities 4.1-8, 4.1-9, 4.1-10) were
written by Dr Vinod Shah, Department of Distance Education, CMC Vellore.

The distance learning modules are the intellectual property of Christian

Medical College, Vellore. They may freely be reproduced. If they are being
modified or used as part of another course, specific permission should be
obtained from the Course Organiser at the distance learning centre, CMC.
 STUDENT’S TIMESHEET

TOPIC Minutes
Activity 4-1.1 Airway
Introduction, Trauma in perspective, ABCDE
Reading of trauma, Airway management

Activity 4-1.2 Basic life support

Reading Basic life support
Activity 4-1.3 Breathing
Ventilation (Breathing) management
Reading Chest trauma

Activity 4-1.4 Limb trauma & abdominal trauma

Reading Circulatory resuscitation methods
Abdominal trauma
Limb trauma, Limb support
Shock and circulation

Activity 4-1.5 Head injury - I

Reading Secondary survey
Head trauma
Activity 4-1.6 Head injury - II
Reading Head injury
Activity 4-1.7 Head injury - III

Activity 4-1.8 Burns management - I

Reading Burns
Burns
Burns management
Activity 4-1.9 Burns management - II
Reading Burn wound management
Electrical and chemical burns

Activity 4-1.10 Burns management - III

Activity 4-1.11 Trauma care for a pregnant patient

Special trauma cases, Pregnancy

Activity 4-1.12 Anaphylaxis

Anaphylaxis

Activity 4-1.13 Drowning

Drowning

Activity 4-1.14 Triage

Reading Trauma response
 May 2012

Dear Student,

PGDFM, We need your feedback will be a great help to us in refining the course for future
students.

In particular, we are keen to know whether the distance learning modules can be completed
in the stipulated timeframe. So we would like you to mark the time you took to complete
each section of each module on a “Student Timesheet” that will be sent to you with each
module. Can you please put down the time you took or the time started and finished - on the
Timesheet. The Timesheet is patterned exactly the same as the Contents page of the module
so that it will be easy for you to enter your timings.

Please do not enter any estimated time but only the exact time taken. If you have not
noted the time or have not completed the Reading / Activity, please leave the Timings
unfilled. This is not for us to monitor your work – it will just be a great help to us if you fill
it in accurately. Please send in the Timesheet along with your TMA and module
evaluation form when you have completed the module.

Thank you very much for your cooperation.

With best wishes,

PGDFM Course Coordinator

 OVERVIEW

Most countries in the world, including ours, are experiencing an ‘epidemic of

trauma’. The most spectacular increase has been in developing countries where
the number of roads and vehicles has increased without a parallel increase in
preventive measures, trained rescue teams or medical facilities leading to a great
increase in morbidity and mortality.

Some of the problems cited are:

• The great distances over which casualties have to be transported to medical
facilities leading to wastage of valuable time before definitive care;
• The absence of skilled people to provide this care.

To address this problem, we need to equip all doctors, medical personnel and even
common citizens to be good ‘first responders’ for common trauma situations
including road accidents, burns and drowning. Learning these skills will lead to a
dramatic increase in the number of survivors and improved outcomes for those who
survive such accidents.

We hope that the module and training you receive during the contact sessions will
help you become more confident in handling all kinds of trauma, and that it will help
you improve the trauma care at your hospital.

To start off, let us look at the following scenario:

− A 27 year old man is brought to the ER following a road traffic accident.

− He is disoriented, has a scalp bleed, raccoon eyes and an oro nasal bleed.
− He is restless, thrashing around, and speaking incoherently, perhaps under
the influence of alcohol.
− His breathing is rapid and shallow. Bystanders who brought him tell us, he
was lying in a pool of blood. His clothes are soiled in blood and dirt, and he
 has multiple external bruises over all four limbs, chest and abdomen. He has
no relatives accompanying him and the only history is from bystanders who
picked him up.

Questions:

- How do you proceed in this scenario?

- How will you prioritise the steps in resuscitation?
- If he were to arrest in your Emergency Room, how you would proceed with CPR?
- What are the instruments, equipment, drugs and IV fluids you have in your ER?
Do you have a defibrillater?
- Is your ER well organised?
- How often do you have CPR “Mock Drills” in your hospital? Who are your team?
- Are you aware that CPR can be taught without the help of expensive ‘manikins’?

When you complete this module, we expect you to have the theoretical base to
manage this case, and organize trauma care services at your hospital. The contact
classes will improve your practical skills in trauma care.

This module has been prepared as a workbook with readings from “Primary
Trauma Care Manual” by Douglas A Wilkinson and Marcus W Skinner.
 ACKNOWLEDGEMENTS

I have a number of people to thank for their help in the preparation of this module.
Dr. Tony Thomson Chandy for the chapter on burns, Dr. Raj for the chapter on
drowning and others, Dr. Amar on anaphylaxis, and the World Federation of
Societies of Anaesthesiologists whose Primary Trauma Care Manual and Update in
Anaesthesia are the main resource reading materials for this module.
- Dr Rebecca Jacob

******
 OBJECTIVES
After you complete the module you should be able to
1. Recognize (and prioritize) and assess multiple injuries (primary survey).
2. Manage life threatening injuries in the initial phase.
3. Go on to a secondary survey and prepare for definitive management.
4. Learn to recognize, assess & treat shock.
5. Prepare the patient for transport to a larger hospital with more facilities.
6. Learn to triage and manage mass casualties.
7. Recognize and treat a case of anaphylaxis.

During the first contact course you will learn skills for Basic Life Support (BLS) and
Advanced Cardiac Life Support (ACLS) along with Triage, Primary Survey,
Secondary Survey, stabilization of the patient, and safe transport to a hospital or
area of greater care. It is good to study this module as you prepare for the contact
course. At the end of this module and the contact session, you may even be able to
set up short courses on Primary Trauma Care (PTC) and BLS in your hospital.
CONTENTS
 TOPIC Minutes Page nos.
Activity 4-1.1 Airway 10 9
Introduction, Trauma in perspective, ABCDE
Reading of trauma, Airway management 10 PTC 3-7

Activity 4-1.2 Basic life support 10 13

Reading Basic life support 5 71
Activity 4-1.3 Breathing 10 17
Ventilation (Breathing) management PTC 8
Reading Chest trauma 10 PTC 14-16

Activity 4-1.4 Limb trauma & abdominal trauma 10 19

Reading Circulatory resuscitation methods 5 PTC 10-11
Abdominal trauma 5 PTC 17-18
Limb trauma, Limb support 5 PTC 23-24
Shock and circulation 10 72-73

Activity 4-1.5 Head injury - I 10 21

Reading Secondary survey 5 PTC 12-13
Head trauma 5 PTC 19-20
Activity 4-1.6 Head injury - II 10 25
Reading Head injury 15 75-87
Activity 4-1.7 Head injury - III 10 31

Activity 4-1.8 Burns management - I 15 37

Reading Burns 5 PTC 28
Burns 5 88-93
Burns management 10 94-100
Activity 4-1.9 Burns management - II 10 41
Reading Burn wound management 5 100-104
Electrical and chemical burns 5 104-106

Activity 4-1.10 Burns management - III 10 45

Activity 4-1.11 Trauma care for a pregnant patient 10 49

Special trauma cases, Pregnancy 10 PTC 25-27

Activity 4-1.12 Anaphylaxis 15 51

Anaphylaxis 15 108-111

Activity 4-1.13 Drowning 10 57

Drowning 10 111-114

Activity 4-1.14 Triage 20 61

Reading Trauma response 5 PTC 35
Mass casualties and triage 10 115-116
INSTRUCTION: Let us start with an activity introducing airway management in
trauma care. Before you start, read pages 3-7 in your textbook “Primary Trauma
Care Management”.. Then proceed to the activity

ACTIVITY 4-1.1 [TIME: 10 MIN]

AIRWAY MANAGEMENT

Venkat aged 14 was walking along the road when a car swerved to avoid a
dog and hit him. He was knocked off his feet and his face hit the curb
knocking in 3 of his front teeth. You are standing on the pavement and run to
help.

1. What is your management priority?

2. You call for help but no one knows what to do. Venkat seems semi
conscious and is making gurgling sounds. What will you do?
3. What makes airway management difficult?
 F E E DB AC K 4 -1
1.1

1. What is your management priority?

Management priorities are to do a quick primary survey and check

A – Airway
B – Bleeding
C – Circulation
D – Disability
E – Exposure

2. You call for help but no one knows what to do. Venkat seems semi conscious
and is making gurgling sounds. What will you do?

If he is making gurgling sounds his airway is obstructed – clear the airway – beware
of pushing his broken teeth into hi
his throat.
− Jaw thrust (Chin lift may cause further cervical damage)
− Cervical spine stabilization
− You may have to place him in the recovery position to prevent bleeding into
the throat or his tongue falling back. Take special care of his neck during this
maneuver.
3. What makes airway management difficult?

Patient injuries
Blood in the airway
The burnt airway
Cervical spine injury (Known or suspected)
Facial injury
Airway injury (laryngeal fracture, tracheo-bronchial injury)

Patient status prior to injury

Body morphology and obesity
Arthritis with reduced movement of occiput on C1 vertebra
Poor mouth opening
Congenital anomalies
Respiratory disease e.g. Asthma
Neonates and children
Non Patient factors
Personal skill of doctor
Quality of assistance
Equipment

How does airway obstruction kill?

‘Oxygen Starvation’ – plain and simple

Always start life support by first opening the airway – you can examine injuries
later.
INSTRUCTION: The following activity aims to teach you about basic life support.
Please read “Basic Life Support” (pg.71) at the back of this module, and then
attempt the activity.

ACTIVITY 4-1.2 [TIME: 10 MIN]

BASIC LIFE SUPPORT

During evening rounds, you find a patient is not responding to commands

and has an altered breathing pattern.

1. What is the first thing you will do?

2. What does ABC stand for?

3. If the patient has an airway obstruction how can you diagnose and manage
it?
4. If the airway obstruction is cleared, how can we check whether the patient’s
breathing is adequate?

5. After having taken care of the patient’s airway and breathing, how will you
assess the patient’s circulatory status?

6. What can we do for a patient having a clear airway, normal breathing and
adequate circulation but not responding to stimuli as an immediate
precautionary measure?

7. Where can you perform BLS and who are the persons who can perform it?
 F E E DB AC K 4 -1 . 2

1. What is the first thing you will do?

The first thing to be done is to “CALL FOR HELP” and start basic life support for a
patient not responding to commands. Try to ‘SHAKE & SHOUT’ to see if the
patient responds or wakes up.

2. What does ABC stand for?

A – Airway B – Breathing C – Circulation

3. If the patient has an airway obstruction how can you diagnose and manage
it?

Airway obstruction can be diagnosed by looking for the following:

a) Snoring or gurgling
b) Stridor
c) Agitation (hypoxia)
d) Use of accessory muscles
e) Paradoxical chest movement
f) Cyanosis

Airway assessment can be performed in 3 steps

a) Look
• Colour
• Respiratory distress
• Conscious state
• Chest movement
b) Listen
• Breath sounds
• Respiratory distress
c) Feel

Basic techniques of Airway management are:

a) Chin lift
b) Jaw thrust
c) Head tilt
4. If the airway obstruction is cleared, how can we check whether the patient’s
breathing is adequate?

Look, listen and feel for respiratory excursions and breath sounds.

5. After having taken care of the patient’s airway and breathing, how will you
assess the patient’s circulatory status?

a) Feel for a pulse – carotid, femoral and radial. These should give you
a rough idea of the systolic blood pressure.
b) Capillary refill will give you an idea of perfusion as will the
temperature of the extremities and tip of the nose.

6. What can we do for a patient having a clear airway, normal breathing and
adequate circulation but not responding to stimuli as an immediate
precautionary measure?

Place him in the lateral recovery position.

7. Where can you perform BLS and who are the persons who can perform it?

a) Anywhere
b) Anyone who is trained to do BLS
INSTRUCTION: The next activity is about breathing management. First read pages
8, 14-16 in your textbook “Primary Trauma Care Management”.. ThenT you can
attempt the activity.

ACTIVITY 4-1.3 [TIME: 10 MIN]

BREATHING MANAGEMENT

A 47 year old male mett with an accident. He was brought to the emergency
room with complaints of breathlessness and pain in the left side of his chest.
He looked irritable, pale, and tachypneoic. On examination, his HR was
140/min, BP, 80/60 mmHg and respiratory rate – 40/min. in. Accessory muscles
were in use. On respiratory system examination, the trachea was shifted to
right side. Tactile crepitations were felt over the 3rd, 4th & 5th ribs on the left
side with no air entry also on the same side. Heart sounds were muffled.

1. How will you evaluate and resuscitate this patient?

2. What are the differential diagnoses?

3. What is the possible immediate management of these differential diagnoses?

 F E E DB AC K 4 -1 . 3

1. How will you evaluate and resuscitate this patient?

ABCDE
After checking and maintaining the airway, the second priority will be ventilation
(Breathing).

LOOK for respiratory rate, cyanosis, use of accessory muscles, penetrating injury,
flail chest, sucking chest wounds.
FEEL for tracheal shift, broken ribs, subcutaneous emphysema (percuss for pneumo
and haemothorax).
LISTEN (AUSCULTATE) pneumothorax (decreased breath sounds) and abnormal
sounds.

2. What are the differential diagnoses?

Differential diagnoses are:

Tension pneumothorax, pneumothorax, haemopneumothorax, haemothorax, flail
chest, haemo mediastinum.

3. What is the possible immediate management of these differential diagnoses?

Maintenance of
Airway
Supplemental oxygen, if available
Diagnosis may be confirmed by clinical signs and chest Xray.
In all cases insert a wide bore IV line and take a sample of blood (haemo
thorax or haemomediastinum) and start an infusion of a balanced salt
solution.
Chest drainage tube with underwater seal
Analgesia – Beware respiratory depression with too much narcotic.

Tension pneumothorax
pneumothorax- The patient is acutely ill and needs URGENT
management. DO NOT SHIFT FOR CXR IF TENSION PNEUMOTHORAX IS
INSTRUCTION: Activity 4 4-1.4
1.4 is about limb trauma and abdominal trauma. Read
pages 10-11, 17-18 18 and 2323-24 in “Primary Trauma Care Management”.
Management” Also
study the readings: “Shock and circulation” (pgs.72-73) 73) at the back of this
module. After this, you can attem
attempt the activity.

ACTIVITY 4-1.4 [TIME: 10 MIN]

LIMB TRAUMA & ABDOMINAL TRAUMA

A 40 year old man was brought to the casualty with history of having been run
over by the rear wheel of a bus while he was getting down. He is awake,
restless, complaining of severe pain in his lower abdomen.
On examination, his HR was 140/min, BP: 80/50mm Hg and RR: 38/min with
poor capillary refill. He has an angulated deformity of the right thigh with
crepitus on palpation and edema.

1. How will you evaluate a

and resuscitate this patient?

2. After the initial resuscitation, the patient is still hypotensive and becomes
confused. On examination you have found tenderness on manual pelvic
compression and abdominal distention. What could be the probable causes?
3. How do you deal with it?
 F E E DB AC K 4 -1 . 4

1. How will you evaluate and resuscitate this patient?

The initial evaluation and resuscitation consists of

A – Airway with cervical spine
B – Breathing: look
FEEL
LISTEN (AUSCULTATE)
- supplemental O2 whenever possible
C – circulatory assessment consists of
- BP, HR, capillary refill, peripheral temperature, peripheral colour,
urine output and Respiratory Rate

2. After the initial resuscitation, the patient is still hypotensive and becomes
confused. On examination you have found tenderness on manual pelvic
compression and abdominal distention. What could be the probable causes?

You missed the pelvic fracture, didn’t you?

Closed fracture femurur blood loss can be upto 1.5 – 2L.
Similarly, with a pelvic fracture - 3L of blood may be lost.
Blunt injury abdomen could also lead to blood loss into the abdomen,
hypovolaemia and abdominal distention

3. How do you deal with it?

Management of this condition consists of

A with spine
B + O2
C - 2 wide bore IV access (send blood for Hb, blood grouping and cross
matching)
Stop obvious bleeding if any
Fluid resuscitation with balanced salt solution (warm if possible)
Analgesia
Maintenance of temperature
Stabilization of fractured limb and pelvis (Beware of Fat Embolization]
NO TOURNIQUET
Transfer to hospital facility for further management of pelvic fracture and intra-
intra
abdominal exploration.
INSTRUCTION: In the next activity, you will learn how to manage a case of head
injury. Before beginning, read pages 12-13 and 19-20 in the PTC manual.
manual Then
attempt the activity.

ACTIVITY 4-1.5 [TIME: 10 MIN]

HEAD INJURY - I

You are the only doctor on duty working in a 50 50-bed

bed hospital on a Sunday
morning. Ramesh, a pillion rider, was thrown off the back of a two-wheeler
two at
the corner outside your hospital and is brought in to your Accident and
Emergency Department.
Ramesh, who looks to be in his mid twenties, is unconscious, responding
only to painful stimuli by moving only his right upper limb. His breathing is
slow and stertorous with a respiratory rate of 14 pe
perr minute. His pulse is 60
per minute and BP 130/90

1. What further assessment would you like to do on site?

2. He regains consciousness for a short while, then lapses into

unconsciousness. His right pupil is dilated. What is your probable diagnosis?

3. What intervention is required?

4. Are their any investigations you would like to do?

5. If you have the facilities for a surgical intervention, what is your treatment of
choice?

6. How will you organise safe transport of this patient to a larger facility which
can take care of him?
 F EE DB AC K 4 -1 . 5

1. What further assessment would you like to do on site?

Primary survey and Secondary survey + Neurological examination and
examination of pupils.

2. He regains consciousness for a short while, then lapses into

unconsciousness. His right pupil is dilated. What is your probable diagnosis?

Extradural haematoma – right side

3. What intervention is required?

Start IV line, stabilize the neck, give oxygen a

and call for help.
Prepare for airway intervention (Endotracheal tube if necessary).

4. Are their any investigations you would like to do?

X-ray skull – if available but do not waste time if he is deteriorating.

Feedback contd on the next page

5. If you have the facilities for a surgical intervention, what is your treatment of
choice?

Burr hole decompression is life saving. Do it if at all possible. He may not last
the journey.

6. How will you organise safe transport of this patient to a larger facility which
can take care of him?

Call the receiving hospital and ensure they are ready to accept the patient.
Document your findings and send with the patient.
Stabilize the neck.
IV – normal saline only. Do not overload.
Airway and breathing to be ensured. Intubate and ventilate (AMBU bag with or
without oxygen).
INSTRUCTION: The next activity continues your learning on head injury through a
few case studies. Before beginning, read “Head injury” (pages pages 75-87)
75 in the
reader at the back of this module. Then attempt the activity.

ACTIVITY 4-1.6 [TIME: 10 MIN]

HEAD INJURY - II

Case 1: 28 year old Sirajuddin, a scooter rider, has had a major accident with
an oncoming car a few hours ago. He has been brought to you in a state of
stupor. He has some blood and some serous fluid issuing out of his nostrils.

a) Does he have a fracture?

b) What will you do?

Case 2: Mahesh is a 20 year old college student who was riding his motor
cycle and hit a car on the side. He is brought to you by an auto-rickshaw
auto
driver. He smells of alcohol. His ABC seems fine. You then do his Glasgow
Coma Scale and the results are as follows:

When you talk to him pointedly, he seems to open his eyes.

He does respond to questions but seems slightly confused.

When you ask him to raise his arm, he does so.

a) What is his GCS score and how will you express it? Is this mild/moderate or
serious HI?
Mahesh’s friends are there with you and they tell you to discharge him so that
he can go home. They tell you that he is confused only because of the alcohol
and has nothing to do with the head injury.

b) Will you discharge him?

Case 3: Ahmed Basha, a 30 year old driver of an automobile has had a head
injury. The relatives want to know the “condition” of the patient.

a) What are the various factors you will evaluate to know the seriousness?

GCS done on Basha 20 minutes after he regained consciousness had the

following results:
• Opens his eyes to speech
• Responds to commands but is confused
• Localizes the pain on supraorbital pressure
He had a history of unconsciousness that lasted for 10 minutes and then had
an episode of vomiting. He has had no seizures, no focal neurological deficit,
no bleeding, and no papillary abnormalities.

b) Will you do a CT scan?

Case 4:III. 58 year old Ramasudesh, has been brought to you with a head
injury, sustained about an hour and a half ago. He fell down from the stairs
and rolled down 12 steps rapidly.
His GCS is 12 and his pupils seem normal. However his BP is 90/60.
The relatives are on their way to your clinic and you have to manage him.

a) Why does he have hypotension and what will you do?

b) Ramasudesh could have primary head injury and secondary brain damage.
Explain.
 F E E DB AC K 4 -1 . 6

1. a) Does he have a fracture?

irajuddin, like many in our country was not wearing a helmet; if only he was!! The
Sirajuddin,
fact that he has serous fluid issuing out of his nostrils is a pointer to the fact that
he has possibly a fracture of his base of skull with CSF rhinorrhea.

c) What will you do?

1. ABC
2. Take a history and do an examination
3. Immobilize neck with collar.
4. Start IV line.
5. Plan on CT scan or X
X-ray
ray skull to rule out base of skull fracture
6. Refer to nearest tertiary care centre (in view of CSF leak)

2. a).What is his GCS score and how will you express it? Is this mild, moderate or
serious HI?

His GCS score is Eyes - 3 plus, Verbal - 4 plus and Motor response - 6. It can be
expressed as follows: GCS = E3 + V4 + M6 = 13 at 8:45 pm. Please note that the
time should be mentioned as it can improve or deteriorate.
This is mild head injury as the GCS is 13. Less than 13 is moderate and less than
8 is severe head injury.
b) Will you discharge him?

No, I will not discharge him for two reasons. One is that only patients with a GCS
of 15 can be discharged. Secondly, one cannot assume that the GCS is low
because of alcohol; it may be, but such an assumption cannot be made.

3.a) What are the various factors you will evaluate to know the seriousness?

His GCS score is E3 + V4 + M5 = 12 done at time….. (mention time)

b) Will you do a CT scan?

Yes a CT is indicated (See indications for CT). If the GCS score is less than 13,
a CT should be done.
4.a) Why does he have hypotension and what will you do?

The hypotension can be due to bleeding inside the skull or can be due to
bleeding from other causes like an abdominal injury or a cervical injury.
Diabetes & Hyponatraemia are other causes that should be borne in mind.
One should never assume that head injury per se has produced hypotension.
Hypotension, if not managed well and early, will reduce the cerebral perfusion
pressure and cause neuronal damage.
After making sure that he is not bleeding externally, start Ringer lactate or
Dextrose Saline and then send him for CT scanning. If there is evidence of
bleeding, then blood needs to be cross-matched.

b) Ramasudesh could have primary head injury and secondary brain damage.
Explain.
Primary injury happens as soon as there is the trauma. Secondary injury refers
to subsequent following continued insult as a result of

Severe hypertension

Hypoxia

Elevated intracranial pressure

Pyrexia causes increased metabolic demand and vasodilatation which
further increases intracranial tension

Hyperglycemia causes lactic acidosis which causes vasodilatation

Seizures also increases the demand for oxygen

Infection adds insult to injury

Vasospasm causes decreased perfusion

Hyponatremia
This can cause neuronal injury and death of the neuronal cells. This is called
secondary injury and is preventable. Hypotension should be promptly managed
to prevent further insult to the neurons. Trauma can precipitate hyperglycemia
and this should be checked for and corrected.
INSTRUCTION: The next activity has some cases of head injury. Please revise
pgs.75-87 before you start the activity.

ACTIVITY 4-1.7 [TIME: 15 MIN]

HEAD INJURY - III

Case 1: Prakash an 18 year old lad has had a fall from a mango tree and he
has the following results of the Best of Eye/Motor/Verbal response (GCS)

Eye opening to pain

Incoherent words

Localizes pain

a) What is his GCS score and how will you manage him?

Case 2: 71 year old Abhijit had a fall in the bath where he slipped and fell. He
was unconscious for several minutes and then when there was no sign of
him, his wife pushed open the bathroom door and found him sitting dazed.
The history is that he was confu
confused
sed for about 10 minutes and then was his
normal self again.
However after about 4 hours, he began to feel drowsy and confused again and
began to complain of a headache.
He is brought to you and you find his GCS is 12.

a) What is this phenomenon cal

called
led where Abhijit was “normal” between two events
of confusion?

b) What is your line of management?

 d) Please study the CT picture on the photosheet at the back of the module.
What do you see?

Case 3: 70 year old Radha comes to you with a history of acute onset of
headache, confusion and some gait disturbance, all for the last one week. She
is not a known diabetic or a hypertensive. On examination she has some
weakness of the right lower limb. You ask for a history of head injury but
none was forthcoming except once some 3 weeks ago. When the lights had
gone out, Radha had hit her head against the stone wall in the darkness. It
was not anything major.

a) How will you manage her?

b) How can a trivial injury cause a subdural hematoma?

c) If Radha has evidence of a chronic subdural hematoma, what CT appearances

do you think will be on the X-ray and how will it be different from an acute subdural?
Case 4: a) What does this CT (see photosheet at the back of the module) of a
patient with headache and dizziness show? He had a history of a minor head
trauma.

b) What are the strategies to reduce the increase in intracranial pressure?

 F E E DB AC K 4 -1 . 7

Case 1:
a) What is his GCS score and how will you manage him?

His GCS is E2 + V3 + M5 = GCS 10 taken at (mention time)

He needs to have a CT and if it is normal and if he does not have any Red flags as
in Guidelines I and if he satisfies the conditions in Guidelines II, he may be
admitted for observation.
Monitoring schedule during admission should follow Guidelines III
If there are deteriorating signals as in Guidelines IV then he may be referred.
If he is well and satisfies the Guidelines V, he may be discharged.

Case 2:

a) What is this phenomenon called where Abhijit was “normal” between two events
of confusion?

This is called “lucid interval” and often occurs in patients with head injury.

b) What is your line of management?

You should order a CT scan because his GCS is 12 and because he has had a
recurrence of symptoms (lucid interval).
c) Please study the following CT scan picture. What do you see?

The hyper dense shadow represents blood and this is the picture one sees in
acute subdural hematoma. Acute subdural hematoma appears hyperdense,
concave toward the brain, and unlimited by suture lines, as opposed to epidural
hematomas, which are convex toward the brain and restricted by suture lines.
To study more details about CT imaging in subdural haematoma access the
following CMC E-learning link
http://e-learning.cmcvellore.ac.in/view/url/1314Q/1485
”Lecture on Subdural hematoma, Lucid interval, Glasgow Coma Score, Extradural
hematoma, Depressed skull fracture, Meningocele, Myelomeningocele by
Dr.Rajshekar”

Case 3:

a) How will you manage her?

The commonest cause of weakness of the lower limb is a stroke; however

Radha was neither a diabetic nor a hypertensive. Hence one should rule out
subdural hematoma by doing a CT scan. The thing to remember is that
chronic subdural hematoma can occur after a very trivial injury.

b) How can a trivial injury cause a subdural hematoma?

In the elderly, the brain atrophies and there is a potential space between the
meninges and the brain. The veins crossing the space get stretched as the
brain has atrophied and so is liable to get torn even by a trivial injury.

c) If Radha has evidence of a chronic subdural hematoma, what CT appearances

do you think will be on the X-ray and how will it be different from an acute subdural?

The CT appearance of a Chronic subdural will be that of a crescentic hypodense

shadow. The appearance of an acute subdural is hyperdense.
Case 4: a) What does this CT of a patient with headache and dizziness show? He
had a history of a minor head trauma.

It shows a hypo dense crescentic shadow without a midline shift. Suggestive

of a chronic subdural hematoma.

b) What are the strategies to reduce the increase in intracranial pressure?

Elevation of head

Hyperventilation

Vetriculostomy

Mannitol therapy

Thiopentone infusion

Decompression surgery
INSTRUCTION: The next activity teaches you how to deal with a case of burns.
First read pg.28 in the PTC manual as well as the sections: “Burns” (pgs.88-93)
(pgs.88
and “Burns management” (pgs (pgs.94-100) and “Burns Algorithm” (pg.107) in the
Readings at the end of the module. Then proceed to the activity.

ACTIVITY 4-1.8 [TIME: 15 MIN]

BURNS MANAGEMENT

Case 1: 28 year old Radha was boiling water on the kitchen platform. When
she was trying to remove the big pot of water from the stove, she slipped and
fell and spilled the boiling water all over herself.

a. What thermal injury would you call this? Is it le

less
ss serious than being burnt by a
flame?

b. If the front of her chest (not abdomen) and half of both upper limbs were involved,
what would be the extent of burns?

c. What one feature will define scalds?

2. List the patho-physiological changes in the following organs following severe
burns:

a. Skin:

b.Kidney:

c.Immunity:

d.Hematologic changes
 F E E DB AC K 4 -1 . 8

1. a. What thermal injury would you call this? Is it less serious than being burnt by a
flame?

Scalds. These are less serious than flame burns as the temperature of boiling
water is never more than 100 degrees C while flame burns can generate much
higher temperatures.

b. If the front of her chest (not abdomen) and half of both upper limbs were involved,
what would be the extent of burns?

18% burns calculated as follows: 9% for the anterior part of the chest + 4.5% for
each half of the upper limbs.

c. What one feature will define scalds?

The presence of blisters.

1. How will you manage this patient?

2. List the patho-physiological changes in the following organs following severe
burns:
a.Skin:

Zone of coagulation – When a patient suffers burns, the tissue closest to the
flame gets the most thermal energy and varying amount of tissue gets
coagulated. This tissue is dead tissue.
Zone of stasis – There is a zone of tissue beyond the coagulated tissue which
is characterized by vascular stasis. This can be salvaged by good burn care but
exposure to air and dehydration of this layer without skin cover prevents any
recovery of this zone as it undergoes desiccation and necrosis.
Zone of Hyperemia – This zone shows minimal injury and recovers over a
period of 7-10 days with prominent vasodilatation with increased blood flow.

b. Kidney:
Oliguric renal failure

Hypovolemia following burn injury results in decreased renal perfusion
and finally decreased urine output.

As in any trauma, increased ADH and aldosterone lead to increased
reabsorption of water and conservation of sodium resulting in
concentrated urine.

Increased amount of myoglobin and hemoglobin and other toxic
products result in decreased urine output.

c. Immunity:
Injury damages the skin barrier function. Suppression of both the cellular and
humoral immunity leads to immunosuppressant in burn victims.
1. Nonspecific – skin first line of defense
2. B-cell mediated humoral response.

d. Hematologic changes
Injury damages the skin barrier function. Suppression of both the cellular and
humoral immunity leads to immunosuppressant in burn victims.
1. Nonspecific – skin first line of defense
2. B-cell mediated humoral response.
INSTRUCTION: The next activity continues to teach you how to deal with a case of
burns. First read the section: “Burn wound management” (pgs.100-104)
(pgs.100 and
“Electrical and chemical burns” (pgs.104-106)
106) in the Readings at the end of the
module. Then proceed to
o the activity.

ACTIVITY 4-1.9 [TIME: 15 MIN]

BURNS MANAGEMENT - II

Prabhavathy, a newly married 24 year old woman, was severely burnt after her
nylon saree caught fire while cooking. When you saw her, the burns involved
the following areas:
Two thirds of the chest and abdomen in the front and one third of the back
was burnt. The whole of the right upper limb, two thirds of the right lower
limb, half of the left lower limb, roughly half of the face and the whole of the
genital area was burnt.

1. Calculate
lculate the extent of the burns.

2. Calculate the fluid requirement if her original weight was 55 kg.

3. How will you manage her?

4. List the indications for admission of a burns patient.

5. What are the principles of wound care in burns?

6. If you were at the site, what immediate measures would you have taken?
 F E E DB AC K 4 -1 . 9

1. Calculate the extent of the burns.

Using the Rule of Nine, abdomen and chest in front is 12%; the right upper limb
is 9%; the right lower limb is 12%; the half of the left lower limb is 9%; the half of
the face is 4.5%, 1/3 back is 6%, the genital area is 1%. The total burnt area is
53.5% (Take 54%).

2. Calculate the fluid requirement if her original weight was 55 kg.

For the first 8 hours: 55 kg.X 47.5% of burns X 2 Plus normal
requirement of 2500 ml = 7725 ml. Half of this should be given in the first
8 hours. Hence about 3862 m
ml should be given.

For the next 16 hours: The rest of the amount, which is about 3863 ml.
should be given in the next 16 hours.

For the next 24 hours: Day 2 - 0.5 ml of colloid/kg/% of burn and 1 ml of
electrolyte solution/kg/% of burns + normal requiremen
requirement.
t. Using this
formula we have: 0.5 X 47.5% burns X 55 kg worth of colloid = 1306 ml
55 X 47.5 plus 2500 ml of normal requirement of Ringer lactate = 5112
ml should be given in the next 24 hours.

3. How will you manage her?

Prabhavathy should be referred. Reasons are that her burns are more than 15%
and they involve the genital areas which are difficult to manage on an outpatient
basis. Consider dowry burns as a possibility; appropriate history should be
taken and the police informed.
4. List the indications for admission of a burns patient:

• Second- or third-degree burns greater than 10% total body surface area
(TBSA) in patients younger than 10 years or older than 50 years
• Second- or third-degree burns greater than 15% TBSA in persons of
other age groups
• Second- or third-degree burns that involve the face, hands, feet,
genitalia, perineum, or major joints
• Electrical burns, including lightning injury
• Chemical burns
• Inhalational injury
• Burn injury in patients with preexisting medical disorders that could
complicate management, prolong recovery, or affect mortality.

5. What are the principles of wound care in burns?

• Prevent dryness and infection – Gently clean of debris and exudate

regularly.
• Pain control – Soak dressings in lukewarm water.
• Prevent trauma – Provide padded occlusive dressings.

6. If you were at the site, what immediate measures would you have taken?

• STOP the source of fire if possible.

• DROP: Lie on the ground.
• ROLL: Roll on the ground and do not run.
• COOL: Pour cold water over the burning garment.
INSTRUCTION: The next activity has a few more cases of burns.

ACTIVITY 4-1.10 [TIME: 15 MIN]

BURNS MANAGEMENT - III

1. Sandra, a 38 year old foreigner was eating in a dhaba; since there was no
place, she was seated near the tandoor which was very hot. Lunch took
about 2 hours and the next day, Sandra was complaining of burning over
the face. On examination, there was erythema over the face but no blister
formation. The sensation was normal and skin was moist.

What kind of burn is this likely to be?

2. Ali a 37 year old man got burnt when he slept with his cigarette in his
hand, but got up soon enough to dous douse e the flame in the mattress quickly.
On examination he has a burnt area on his loin region which is very
painful, pink and moist. What is likely to be the depth of the burn wound?

3. Patekar, a 45 year old man, attempted suicide by pouring petrol over

himself and lighting it with a match stick. He has black, leathery skin and
seems oblivious to pain. What is the likely depth of the burns?
4. 2nd degree superficial burns or 2nd degree deep burns can get converted to 3rd
degree because of ……. Give two factors.
 F E E DB AC K 4 -1 . 1 0

1.. What kind of burn is this likely to be?

This is likely to be a 1st degree burn as radiated heat from a tandoor from a
distance is not likely to produce more than a first degree burn. Skin protective
cream may be prescribed.

2. What is likely to be the depth of the burn wound?

The fact that Ali has pain sensation means that some of his dermis is intact.
Then since the lesion is moist, it means that the sweat glands are also spared.
Therefore he probably has 2nd degree superficial burns.

3. What is the likely depth of the burns?

The fact that the skin is leathery means that he has full thickness burns and this
is also the reason why he has no pain. (The nerves have been destroyed.)
4. 2nd degree superficial burns or 2nd degree deep burns can get converted to 3rd
degree because of ……. Give two factors.

1. Infection

2. Dessication or dryness
INSTRUCTION: In the next activity, you will look at a case of trauma in a pregnant
patient. Before you begin, read pages 25-27 in the PTC manual. After this, you can
c
work out the activity below.

ACTIVITY 4-1.11 [TIME: 10 MIN]

TRAUMA CARE FOR A PREGNANT PATIENT

A 28 year old woman is brought into your emergency room. She was a pillion
rider on a two wheeler and had been thrown off the vehicle following a
collision with a stationary cart. She says she is pregnant, at 33 weeks of
gestation. She is breathless, has a
abdominal
bdominal pain, bleeding PV, and a painful
right arm.

1. How will you assess this patient?

On evaluation you find that the patient is tachypnoiec has a heart rate of
150/min and a blood pressure of 70/30. There is obvious bleeding PV but no
external wounds
ounds over the abdomen. She has an open fracture of the right
ulna.

2. Will pregnancy influence these parameters that you have just evaluated?

You find that there are no obvious spine injuries and have begun
resuscitation with oxygen, established large bore IV access and intravenous
fluid therapy, and have splinted the fore arm.
3. What are the possible reasons for the bleeding PV?
4. What should be your priorities while managing this patient?

F E E DB AC K 4 -1 . 1 1

1. How will you assess this patient?

The first thing to be done is to evaluate the ABC

A: Airway
B: Breathing - LOOK
- LISTEN
- FEEL
Accordingly administer oxygen.
C: Circulation – assessment includes checking the HR, BP, capillary refill,
peripheral temperature, and colour of the skin.
D: Disability - The patient in this case is awake and talking to you.
E: Exposure - She has a p painful
ainful arm which may be because of a fracture. If
a cervical or lumbar spine injury is suspected, in line immobilization and
cervical spine stabilization is important.

2. Will pregnancy influence these parameters that you have just evaluated?

You must keep in mind that pregnant patients have higher heart rates and lower
blood pressure readings, with an increased tendency for aortocaval compression
during the third trimester. Keep her in the left lateral position or place a wedge or
sand bag under
nder her right hip to reduce the aorto caval compression

3. What are the possible reasons for the bleeding PV?

The bleeding may be due to partial or complete rupture of the uterus, placental
separation or following pelvic injuries and fractures.

4. What should be your priorities while managing this patient?

Assess the mother, determine if the mother’s condition will allow you to evaluate
the fetus. If the mother is extremely sick then her resuscitation becomes the
priority. Following the ABCDE mentioned above, resuscitation may be carried in
the left lateral position if there are no spine injuries, to avoid aortocaval
compression.
INSTRUCTION: The next activity takes you through a case of anaphylaxis and the
appropriate treatment required. Please read the section
section:: “Anaphlaxis” (pgs.108-
111) in the reader at the end of the module, and then proceed to the activity.

ACTIVITY 4-1.12 [TIME: 15 MIN]

ANAPHYLAXIS

A 40 year old man in the ward had cellulitis foot. The physician prescribed
intravenous penicillin to treat the infection. The patient developed breathing
difficulty, giddiness, and itching over the body. On examination, he was
tachypnoeic, tachycardic and hypotensive.

1. What could be the cause?

2. How do you manage?

3. What are the manifestations of anaphylaxis?

4. How do you diagnose anaphylaxis?

5. How do you treat less severe reactions?

6. What are the differences between anaphylaxis and anaphylactoid reaction?

 FE E DBAC K 4 -1 . 1 2

1. What could be the cause?

It is a case of anaphylactoid reaction.

2. How do you manage?

Immediate Treatment of a Severe Reaction

• Stop administration of the causal agent and call for help.

• Follow the ABC of resuscitation.
• Adrenaline is the most useful drug for treating anaphylaxis as it is effective in
bronchospasm and cardiovascular collapse.
.
A - Airway and Adrenaline

• Maintain airway and administer 100% oxygen.

• Adrenaline. If IV access is available give 1:10,000 adrenaline in 0.5-1ml
0.5
increments, repeated as required. AAlternatively give IM 0.5 - 1mg (0.5 - 1ml
of 1: 1000 solution) repeated each 10 minutes as required.

B - Breathing

• Ensure adequate breathing. Intubation and ventilation may be required.

• Adrenaline will treat bronchospasm and swelling of the upper airway.
• Nebulised bronchodilators (e.g. 5mg salbutamol) or IV aminophylline may be
required if bronchospasm is refractory (loading dose of 5mg/kg followed by
0.5mg/kg/hour).

C - Circulation

• Assess the circulation. Start CPR if cardiac arrest has occurred.

• Adrenaline is the most effective treatment for severe hypotension
• Insert 1 or 2 large bore i/v cannulae and rapidly infuse normal saline. Colloid
may be used (unless it is thought to be the source of the reaction).
• Venous return may be aided by lifting tthe
he patient's legs or tilting the patient
head down.
• If the patient remains haemodynamically unstable after fluids and adrenaline
- give further doses of adrenaline or an intravenous infusion (5mg in 50mls
saline or dextrose 5% through a syringe pump, or 5 5mg
mg in 500mls saline or
dextrose 5% given slowly by infusion). Uncontrolled intravenous boluses of
adrenaline can cause dangerous surges in blood pressure and arrhythmias.
Give the drug carefully, observing the response and repeating when
required. Try to monitor
onitor the ECG, blood pressure and pulse oximetry.
 Further Management

• Give antihistamine agents. H1 blockers eg chlorpheniramine (10mg i/v) and

H2 blockers ranitidine (50mg i/v slowly) or cimetidine (200mg i/v slowly).
• Corticosteroids Give hydrocortisone 200mg i/v followed by 100-200mg 4 to
6 hourly. Steroids will take several hours to work.
• Make a decision whether to cancel or continue with proposed surgery.
• Transfer the patient to a high care area (e.g. intensive care or high
dependency unit) for further observation and treatment. Anaphylactic reactions
may take several hours to fully resolve and the patient must be closely
observed during this time.

3. What are the manifestations of anaphylaxis?

The commonest features are cardiovascular. Not all signs occur in every
patient - one feature may be more obvious than others. Reactions range
from minor to life-threatening.

• Cardiovascular: Hypotension and cardiovascular collapse. Tachycardia,

arrhythmias, ECG may show ischaemic changes. Cardiac arrest.
• Respiratory System: Oedema of the glottis, tongue and airway structures
may cause stridor and airway obstruction. Bronchospasm - may be severe.
• Gastrointestinal: There may be abdominal pain, diarrhoea or vomiting.
• Haematological: Coagulopathy
• Cutaneous: Flushing, erythema, urticaria

4. How do you diagnose anaphylaxis?

Diagnosis is made on clinical grounds - though it may not be possible to define

exactly which agent precipitated the attack. Make a record of events in the notes
and when appropriate inform the patient and his/her general practitioner. If the
patient requires further anaesthesia or surgery avoid the use of the suspected
precipitating agents.

Some specialised laboratories can estimate Tryptase (a breakdown product of

histmine) which can help to confirm the diagnosis. Take blood into glass tubes 60
minutes after the reaction. This test is unavailable in many places.
 5. How do you treat less severe reactions?
Treatment is similar to the regime above, but i/v adrenaline may not be required.
Manage the ABC as described, and assess the response. Drugs such as ephedrine
or methoxamine may be effective to treat hypotension along with i/v fluids.
However, whenever the patient's appears to be worsening always use adrenaline.

6. What are the differences between anaphylaxis and anaphylactoid reaction?

Anaphylaxis
Anaphylaxis is an exaggerated response to an antigen that cross-links with IgE
immunoglobin triggering the release of inflammatory mediators like histamine,
leukotrines and platelet activating factors from mast cells occurring in a sensitized
person.
Anaphyactoid reactions
Anaphylactoid reactions are direct, non immune mediated release of inflammatory
mediators from the mast cells. It does not require prior sensitization.
INSTRUCTION: The next activity is about trauma care in a case of drowning.
Before you start the activity,
tivity, please read the section
section: “Drowning” (pgs.111-114)
(pgs.111 in
the reader at the end of the module. Then you can begin the activity.

ACTIVITY 4-1.12 [TIME: 10 MIN]

DROWNING

On your visit to a nearby swimming pool you hear a man calling for help
though he is near the shallow end of the pool.

1. How will you handle the situation?

2. How is fresh water drowning different from saltwater drowning?

3. With your chest compressions, the victim starts to vomit. How will you manage?
4. How do you clear the airway of water?

5. How do you do the post-resuscitation care?

 F E E DB AC K 4 -1 . 1 3

1. How will you handle the situation?

Get to the victim as quickly as possible with some flotation device. (You must
always be aware of personal safety. People who are drowning are irrational and
can cling to you, causing you also to drown.) Recover the patient from the water –
check responsiveness. If there is no response, call for help and start with Basic Life
Support.
A – No need for cervical spine stabilization unless there is circumstantial evidence
of fall from a water slide, diving from the side, signs of injury or signs of intoxication.
B – Breathing or Ventilation is the most important treatment. There is no need to
clear the airway of aspirated water. There is no need for Heimlich maneuver or
abdominal thrusts. Start with 2 rescue breaths sufficient to raise the chest. Give
supplemental O2 whenever possible.
C – If the patient is not breathing or moving and the health care provider is not able
to palpate the central pulse for 10 seconds (difficult if the patient is cold), start chest
compressions at a rate of 100/min (30 : 2).
D – As soon as 1 fan automatic external defibrillator (AED) is available and the
patient is completely out of the water, shock in case of shockable rhythm i.e. if he
is in ventricular fibrillation or ventricular tachycardia.
E - Warming – by removal of wet clothes and covering with warm blanket. blanke This
should be done as soon as feasible after cardiopulmonary resuscitation.

2. How is fresh water drowning different from saltwater drowning?

Although theoretically different, these are not to be found clinically significant. Salt
water can result in pulmonary edema by diffusion of intravascular fluid into alveoli
and the diffusion of salt water into the bloodstream may result in hypernatremia.
Fresh water diffuses quickly into the bloodstream and results in dilutional anemia
and
nd hyponatremia. But for this you need absorption of 10ml/kg and 20 ml/kg of
water (500- 1000ml) whereas for a drowning victim, you will find just about 150 ml
of water in the lungs. The most important factors determining outcome are duration
and severity of hypoxia.

3. With your chest compressions, the victim starts to vomit. How will you manage?

Turn the victim to one side, clear the airway using finger, cloth or suction. If you
suspect spinal injury, log roll.
 4. How do you clear the airway of water?

There is no need to clear the airway of aspirated water because only a moderate
amount of water is aspirated by a majority of victims, and it is absorbed rapidly into
the central circulation. Some victims aspirate nothing as they develop
laryngospasm or breath holding. So aspirated water does not obstruct the trachea.

5. How do you do the the post resuscitation care?

* Give oxygen if available. * Keep warm.

All victims of drowning who require any form of resuscitation including rescue
breathing should be transported to hospital for evaluation and monitoring even if
they appear alert and have effective cardio-respiratory function at the scene.
Hypoxia causes increased pulmonary capillary permeability with delayed onset of
pulmonary complications.
INSTRUCTION: Finally, we look at the organisation of emergency care by
prioritization of the victims for medical attention. This is called Triage. Read page 35
in the PTC manual, and the section:: “Mass casualties and triage” (pgs.115-116)
in the reader. Then you can begin the activity.

ACTIVITY 4-1.14 [TIME: 30 MIN]

TRIAGE

You are the duty doctor in a busy A&E Dept. in a 200200-bed

bed hospital. Suddenly
you are alerted by the hospital staff following the arrival of some vehicles
carrying the victims of a car vs auto rickshaw collision.

Patient A: Male, Ramu, 28, is an auto rickshaw driver. He was extricated by

onlookers with difficulty from the crushed auto rickshaw. He is unconscious
un
with severe fasciomaxillary trauma with bleeding from the nose and mouth
and is in severe respiratory distress.
Vital Signs: P 90, BP: 160/100, RR 44.

Patient B: 42 year old female, Bharathi, a passenger in the autorickshaw,

found thrown out of the vehicle. Awake, alert, and has abdominal pain. On
palpation of her hips she complains. Vital Signs: P 140, BP: 90/50, RR 35.

Patient C: Male, 38, George, driver of the car, was thrown against the steering
wheel and through the windshield. Confused and responds slowly to verbal
stimuli. Multiple facial, chest and abdominal abrasions. Absent breath sounds
on the left chest.
Vital Signs: P 138, BP: 90/50, RR 35.

Patient D: 4 year old male child, Stephen, extricated from the floor of the rear
seat. Alert and talking at the scene. Now, crying loudly in pain. The right lower
limb has an angulated deformity. Vital Signs: P 180, BP: 110/70, RR 35.

Patient E: 26 year old hysterical female, Mariammal, extricated from the rear
seat of the vehicle. She is eight months pregnant and complains of abdominal
pain. She has abdominal tenderness. Vital Signs: P 180, BP: 110/70, RR 35.

1. What is your first priority?

 2. What are the main priorities in each round?

In line with each patient’s situation as given below, state your response and actions.

A. Ramu is deeply unconscious. Snoring with in drawing of intercostals.

3. What does this indicate? What will you do?

B. Bharathi : Awake, alert and crying in pain. Her airway and breathing seem
alright.

4. Do you need to do anything for her at this point?

C. George: Has facial lacerations and chest injuries. He could have an airway
problem. You check clear the airway. You find poor air entry in left chest with
respiratory difficulty.

5. Do you have a possible diagnosis which requires immediate/ emergent

treatment?
D. Stephen is shouting. He is afraid and in pain, but his airway and breathing
are alright.

6. What needs to be done for this patient?

E. Mariammal’s airway and breathing are alright, but she is in pain.

All the patients must be kept warm.

7. What are the two main actions to be taken in Round 2?

8. State the appropriate care for each of the patients in Round 2.

A.
B.
C.
D.
E.

9. In Round 3, what are your concerns regarding Ramu and how will you
manage them?

10. What are George’s possible injuries and how will you manage them?
11. Mariammal’s legs and hands are getting cold. She may be having internal
injuries. What do you need to do for her?

12. Bharathi appears to have a pelvic fracture. She is alert but cold. Remember
you can lose 2-3 litres of blood from a pelvic fracture with no obvious external
loss.
What needs to be done in case of a possible pelvic fracture?

13. What will do you for Stephen in Round 3?

14. Why is it important to document the care given to each patient? How will you
manage documentation in an emergency?
 F EE DBAC K 4 -1 . 1 4

1. What is your first priority?

Stay Cool, identify helpers and call for help from medical facility nearby.

You will need 3 rounds – 2 mins at each person.

2. What are the main priorities in each round?

Round 1: Check Airway and Breathing, and stop bleeding. Treat as you go.
Round 2: Start IV infusions and administer pain relief.
Round 3: Identify the sickest patients and do a secondary survey.

In line with each patient’s situation as given below, state your response and
actions.

A. Ramu is deeply unconscious. Snoring with indrawing of

intercostals.

3. What does this indicate? What will you do?

He has airway obstruction, clear his airway with suction, (look for broken teeth),
use an appropriate size oral airway and give oxygen. Protect & stabilize his C
spine. Leave him in the care of a nurse or bystander. Ask the nurse to keep a
size 7.5 oral ETT with stilette and a working laryngoscope ready in case his
obstruction gets worse. It is worth keeping a cricothyrotomy needle or
tracheostomy set available
ble considering his facial injuries.

B. Bharathi: Awake, alert and crying in pain. Her airway and breathing
seem alright.

4. Do you need to do anything for her at this point?

No.
C. George: Has facial lacerations and chest injuries. He could have an
airway problem. You check clear the airway. You find poor air entry in left
chest with respiratory difficulty.
5. What should you do for him?
a) Give oxygen
b) He may have a tension pneumothorax. Insert a large bore cannula in 2nd
left intercostal space.
c) Ask staff to prepare for intercostals chest drain (ICD). Could have C
spine injury – use collar and stabilize.
D. Stephen is shouting. He is afraid and in pain, but his airway and
breathing are alright.

6. What needs to be done for this patient?

Reassure him and get help to apply pressure on the femoral artery proximal to
the injury.

E. Mariammal’s airway and breathing are alright, but she is in pain.

All the patients must be kept warm.

7. What are the two main actions to be taken in Round 2?

Start IV infusions and pain relief.

8. State the appropriate care for each of the patients in Round 2.

2 large bore IV cannulae should be inserted for all the victims as all 5 of them
appear to have some damage to a large blood vessel.
Ramu and George who may have had head injuries are better off with IV normal
saline. The others may have Ringer lactate (hypotonic).
Pain relief – Ketamine may be given IV has 0.2 to 0.3 mg/kg except for head
injured patients. Morphine may be given in dozes of 0.1 mg/kg. Beware of
respiratory depression.

9. In Round 3, what are your concerns regarding Ramu and how will you
manage them?

Ramu may need in intubation / tracheostomy and ventilation with C spine

stabilization. As he has a head injury, he will need to be seen by a neuro
surgeon. Prepare for evacuation if definitive neuro surgical care is not available
in your hospital.
10. What are George’s possible injuries and how will you manage them?

George needs urgent airway care and placement of an Intercostal drain (ICD)
as he may have a tension pneumothorax or haemothorax (x-ray – if available
but do not waste time). Protect his C spine (remember he went through the
windshield). Watch vital signs for deterioration of neurological markers and
haemodynamics.

11. Mariammal’s legs and hands are getting cold. She may be having internal
injuries. What do you need to do for her?

Continue IV fluid and oxygen, keep in left lateral position to avoid aortocaval
compression. Do an ultrasound if available. Prepare to do emergency caesarian
section if required.

12. Bharathi appears to have a pelvic fracture. She is alert but cold. Remember
you can lose 2-3 litres of blood from a pelvic fracture with no obvious external
loss.
What needs to be done in case of a possible pelvic fracture?
Stabilise the pelvis, cross match blood. Continue giving crystalloids / colloids.
Keep patient warm and give adequate analgesia and oxygen.

13. What will do you for Stephen in Round 3?

Stephen needs to have his fracture reduced and the leg immobilized. If it is a
bleeding open fracture, apply compression dressing. Prepare to evacuate if you
do not have facilities for orthopaedic surgery.

14. Why is it important to document the care given to each patient? How will you
manage documentation in an emergency?

It is important to document everything.

History and examination of each patient as you do each round. Dictate it to an

aide if you do not have time to do so immediately. This is important in the follow
up management of the cases (especially if you are evacuating a patient) and for
legal documentation.
NOTES
READINGS
 BASIC LIFE SUPPORT

Initial Assessment
In your initial assessment of the patient, you need to check the following:
- Is the patient rouseable?
- Is the patient breathing?
- Does the patient have a pulse?

ABC of Basic Life Support

- Open Airway.
- Rescue Breathing (with bag and mask in hospital).
- IV and Chest compression.
- 30:2 : Chest compression : Ventilation.
- Push hard, push fast – 100 / minute.
- Position palms in middle of sternum.
- Defibrillate.
- Do not pause to assess cardiac rhythm after defibrillation for 2 cycles
of compression and ventilation.

Also refer to Circulation November 2005 – available free on the net.

 SHOCK AND CIRCULATION
Blood loss can lead to shock. The quantity of external blood loss that can occur at
various sites is given below.

Site Quantity of blood loss

Closed femoral fracture 1.5 – 2 litres
Closed tibial fracture 500 ml
Pelvic fracture 3 litres
Rib fracture (each) 150 ml
Haemothorax 2 litres
Hand sized wound 500 ml
Fist sized clot 500 ml

Concealed blood loss leading to shock may occur in sites such as:
 Abdominal cavity
 Pleural cavity
 Femoral shaft
 Pelvic fractures
 Scalp (in children)

Bleeding may be either compressible or non-compressible. Peripheral bleeding is

generally compressible, whereas intra-abdominal locations, for example, will be
non-compressible and will require surgery.

The clinical signs of shock include:

 Altered mental state, which could range from anxiety to coma
 Tachycardia
 Pulse pressure narrowed
  Pulse
- If the radial pulse is felt, the systolic BP is > 80 mmHg.
- If the femoral pulse is felt, the systolic BP is >70 mmHg.
- If the carotid pulse is felt, the systolic BP is > 60 mmHg.
* If the carotid pulse is not felt, the BP is < 60 mmHg and the patient has no
cardiac output – Treat as a cardiac arrest.
 Skin - cold, pale, sweaty, cyanosed
 Capillary refill time > 2 seconds
 Blood pressure (lower)
 Jugular venous pressure (JVP)
 Urine output < 0.5 ml/kg/hr
 Respiratory rate high

The main clinical signs of shock are tabulated below:

Blood loss Heart Blood Capill Resp Mental state
rate pressure return rate
< 750 ml < 100 Normal Normal Normal Normal
750 -1500 ml > 100 Systolic Prolonged 20-30 Mildly anxious
Normal
> 1500 - 2000 ml > 120 Decreased Prolonged 30-40 Anxious,
confused

Cardiogenic shock occurs due to inadequate heart function. This may arise from:
 Myocardial contusion (bruising)
 Cardiac tamponade
 Tension pneumothorax
 A penetrating wound to the heart
 Myocardial infarction

The main elements of circulation management are:

 To secure the airway and breathing (A & B) and give oxygen if required
  To obtain adequate vascular access by inserting two large bore intra-venous
cannulae
 To stop obvious bleeding
 To ensure fluid replacement
 To maintain temperature
 To provide analgesia

Consider blood transfusion when:

 There is haemodynamic instability despite fluids
 Haemoglobin < 7g/dl and the patient is still bleeding

For fluid replacement,

 Warm fluids if possible
 Colloids or crystalloids?
Crystalloids are inexpensive and easily accessible. Give in the proportion of
300-400 ml crystalloid for every 100 ml blood loss.
Colloids like starches and gelatins are more expensive but stay in the
circulation longer. Give if haemodynamically unstable and if blood is not
available.
 Consider hypotensive resuscitation if haemostatis not secure.
 Consider oral resuscitation.
 HEAD INJURY
Definition:
A head injury is any trauma that leads to injury of the scalp, skull, or brain.
Causes:
The most common causes that the family medicine practitioner is likely to see are:
o Falls from trees
o Children falling from cots
o Assaults (lathi-charge), sports-related injuries, and
o Pedestrians struck by motor vehicles, bicycle accidents.
o The male-to-female ratio for head injury is nearly 2:1, and it is much
more common in persons younger than 35 years.
o Patients caught up in high velocity accidents involving motor vehicles,
are often taken to big hospitals; however many less injured come
to the family practitioner.
o Patients with penetrating trauma (bullet injury) also do not usually
come to a family practitioner.

Pathophysiology of cranio-cerebral injury-

The brain is housed within an inelastic container - the skull, and only small
increases in volume within the intracranial compartment can be tolerated before
pressure within the compartment rises dramatically.

This concept is defined by the Monro-Kellie doctrine, which states that the total
intracranial volume is fixed because of the inelastic nature of the skull. The
intracranial volume (V I/C) is equal to the sum of its components, as follows:

V (Intracranial) = V (brain) + V (cerebrospinal fluid) + V (blood)

In the typical adult, the intracranial volume is approximately 1500 ml, of which the

o brain accounts for 87%,

o intravascular cerebral blood volume accounts for 10%, and
o cerebrospinal fluid (CSF) accounts for the remainder (3%).

Volume percentages of
CSF, Blood and the
Brain
CSF -3%

Blood -10%

Brain -87%

When a significant head injury occurs, cerebral edema often develops, which
increases the relative volume of the brain. Because the intracranial volume is fixed,
the pressure within this compartment rises unless some compensatory action
occurs, such as a decrease in the volume of one of the other intracranial
components.

Once the intra cranial pressure rises the cerebral blood flow diminishes, causing
anoxic death of the neural tissue.

Auto-regulation of amount of blood available to the brain by regulation of the

cerebral perfusion pressure:

Small to moderate drops in blood pressure or small to moderate increases in blood

pressure can be regulated by the cerebral arterioles so that the mean perfusion
pressure to the brain is the same. In other words, normally the amount of blood flow
to the brain is constant.
A second crucial concept in head injury pathophysiology is the concept of cerebral
perfusion pressure (CPP). CPP is defined as the difference between the mean
arterial pressure (MAP) and the intracranial pressure.

CPP = MAP – ICP

When the intracranial pressure increases the cerebral perfusion pressure
decreases.

Increased Intra Cranial

Pressure

Decreased cerebral
perfusion pressure

However when there is a steep drop in blood pressure or a steep increase in blood
pressure, auto-regulation does not work; the injury to the brain may yet be another
reason why the auto-regulation mechanism of the cerebral arterioles may be
crippled. Under these circumstances, the brain gets very little blood during
hypotension and neuronal ischemic injury results. When there is hypertension, the
blood flow to the brain increases and this adds to the cerebral volume increasing
the ICP (Intracranial pressure). Increase in the intracranial pressure squeezes the
brain causing anoxic injury.

All of these can cause anoxic injury to

the brain:
Increased intracranial pressure
Moderate to Severe hypotension
Moderate to Severe hypertension
Cerebro-cranial injury may be divided into 2 categories, primary brain injury and
secondary brain injury.

• Primary brain injury is defined as the initial injury to the brain as a direct result of
the trauma. This is the initial structural injury caused by the impact on the brain,
and, like other forms of injury, prevention is the only mode available medically.
•

Helmets can prevent primary brain injury

• Secondary brain injury is defined as any subsequent injury to the brain after the
initial insult. Secondary brain injury can result from

Systemic hypotension,

Severe hypertension

Hypoxia,

Elevated intracranial pressure,

Pyrexia causes increased metabolic demand and vasodilatation which
further increases intracranial tension

Hyperglycemia causes lactic acidosis which causes vasodilatation

Seizures also increases the demand for oxygen

Infection adds insult to injury

Vasospasm causes decreased perfusion

Hyponatremia
The normal ICP or intracranial pressure in adults is
0-15 and in children it is 0-10 mm Hg. ICP causes
decrease in CPP or cerebral perfusion pressure and
anoxic injury or death of the neurons.

It can also cause herniation of the brain through

normal anatomical openings as shown in this
diagram. Herniation of the brain is a serious
complication often leading to death.

Increased ICP causing herniation

Hyperglycemia Hypotension
Vasodilatation

Pyrexia
Seizures

Increased ↓ perfusion
Intracranial pressure &
Hypertension tension Anoxia

Bleeding

Neuronal injury
and death
 Role of the ATTENDING doctor is to
prevent all the above that secondarily
injure the brain.

Kinds of injury
When the stationary head is hit by a moving object, acceleration is imparted to it
and the injury is called accelerative injury. When the moving head is suddenly
brought to a halt as in a moving car that has been hit, decelerative injury occurs.
Two mechanisms of brain injury are operative:

Coup and contre coup injury and

Rotational or Shearing injury
Coup and contre-coup
coup injury: Imagine a situation where the head has been hit as
a moving car has hit a tree (decelerative injury). The skull suddenly comes to halt;
the brain in it does not immediately, but continues to move forwards. It hits the
anterior sections of the skull (anterior and middle fossa) violently and then rolls
backwards and hits the posterior part of the skull. The
direct hit (in this case anterior parts of the brain) is called
the “coup” injury and the indirect injury (in this case
posteriorly) is called the “contre coup” injury.

The anterior parts of the brain that is injured are usually

the frontal and temporal lobes and especially those parts
of the lobe that abut against rough prominent portions of
the skull. The occipital lobe posteriorly is not usually
injured as badly, since the posterior cranial fossa is smooth. This then is how the
contusions in the brain occur. They can bleed and produce a “mass lesion” that can
greatly increase the ICP and be life threatening.

Shearing or rotational injury: When the brain moves forwards and backwards
after impact, it is held at its centre tightly by the
brainstem. A rotational force (torque) occurs and
axons in the white matter in the brain gets stretched.
If they only stretch without breaking, then
concussion results. The patient loses
consciousness
onsciousness shortly for seconds or minutes or
sometimes hours and then recovers. Concussion
then is caused by shearing force. If the rotational
force (torque) is very severe then the axons break
and more profound loss of consciousness results. Some hemorr
hemorrhage
hage may also
result. It is possible to lose consciousness without a great deal of bleeding or
without an increase in ICP and this is attributed to the shearing damage to the
axons. This type of injury is called
called- “diffuse axonal injury”.
 Overview of Head injury management: A 5- step approach

STABILIZE
“ABC”

ASSESS-(HISTORY &
EXAMINATION)

INVESTIGATIONS

REFER BASED ON RED

FLAGS

MANAGE - IF NO RED
FLAGS (In or Out patient)

STABILIZE

Stabilization is about ABC:

ABC stands for AIRWAY, BREATHING, CIRCULATION.

AIRWAY
The airway can be opened by lifting the jaw and tilting the head backwards carefully
(take extra care if you suspect a neck injury).
Carefully clear any debris you can see from the mouth if necessary. Make sure the
tongue isn't blocking the airway.
Then check the breathing.

BREATHING
If opening the airway does not cause the person to begin to breathe straight away
you must provide rescue breathing. The best way to do this is by using the mouth-
to-mouth technique.
Take your hand that is on the person's forehead and turn it so that you can pinch
the nose shut, while keeping the heel of the hand in place to maintain head tilt. Your
 other hand should remain under his chin, lifting up. Immediately give two slow full
breaths, using the mouth-to-mouth method.

CIRCULATION

First you need to check the pulse. The best place to find a pulse is at one of the
carotid arteries.

If there is no pulse you will need to give external chest compression to try and help
the heart beat.
Place the heel of your hand two fingers breadth above the ribcage/breastbone
junction. Place your other hand on top and interlock the fingers. Keep your hands
off the ribs. Keep your arms straight press down four or five cm 15 times.
Give two breaths then check pulse again.
If the casualty has a pulse, do not use external chest compression.
If the casualty has a pulse but is not breathing, continue to give mouth-to-mouth at
the rate of about ten breaths a minute.
In addition:
Oxygen, 100%
 Intubate and hyperventilate if necessary
 beware of a cervical spine injury
 Stop blood loss and support circulation
 Treat for shock if required.
 Treat seizures with diazepam

ASSESS - (HISTORY &

EXAMINATION)

Brief history
• When? Where? How? (Direct blows to the head such as a stone falling are
more serious than deceleration/acceleration injuries)
• Unconscious?
• Lucid interval?
• Antegrade & retrograde amnesia?
• Had a fit?
• Alcohol?
(Antegrade amnesia: Amnesia in which the loss of memory relates to events that
occur after a traumatic event. There is inability to recall new information. Old
information can be recalled. This type of amnesia is in contrast to retrograde
amnesia in which the lack of memory relates to events that occurred before a
traumatic event. Retrograde amnesia does not occur without antegrade amnesia).

Examination:
• General examination (Look for other injuries)
• Cervical examination (Make sure there is no cervical injury before detailed
investigations)
• Neurological examination
• Pupil examination- direct and consensual
• Glasgow coma scale

The Glasgow Coma Scale (GCS) is used to describe the general level of
consciousness of patients with head injury and to define broad categories of head
injury. The GCS is divided into 3 categories, eye opening (E), motor response (M),
and verbal response (V). The score is determined by the sum of the score in each
of the 3 categories, with a maximum score of 15 and a minimum score of 3, as
follows:

GCS score = E + M + V

Best eye response (E)

There are 4 grades:
4. Eyes opening spontaneously.
3. Eye opening to speech. (Not to be confused with an awaking or a sleeping
person; such patients receive a score of 4, not 3.)
2. Eye opening in response to pain. (Patient responds to pressure on the
patient’s fingernail bed; if this does not elicit a response, supraorbital and
sternal pressure or rub may be used.)
1. No eye opening.

Best verbal response (V)

There are 5 grades:
5. Oriented. (Patient responds coherently and appropriately to questions such
as the patient’s name and age, where they are and why, the year, month,
etc.)
4. Confused. (The patient responds to questions coherently but there is some
disorientation and confusion.)
3. Inappropriate words. (Random or exclamatory articulated speech, but no
conversational exchange).
2. Incomprehensible sounds. (Moaning but no words.)
 1. None.

Best motor response (M)

There are 6 grades:
6. Obeys commands. (The patient does simple things as asked
asked.)
.)
5. Localizes to pain. (Purposeful movements towards changing painful stimuli;
e.g. hand crosses midmid-line
line and gets above clavicle when supra-orbital
supra
pressure applied.)
4. Withdraws from pain (pulls part of body away when pinched; normal flexion).
3. Flexion in response to pain (decorticate response).
2. Extension to pain (decerebrate response: adduction, internal rotation of
shoulder, pronation of forearm).
1. No motor response.

Scoring etiquette:

Individual elements as well as the sum of the score are important. Hence, the score
is expressed in the form "GCS 9 = E2 M3 V4 at 07:35 AM".

Generally, head injuries are classified as:

Mild head injuries are generally defined as those associated with a GCS score of 13-15,
13 and

Moderate head injuries are those associated with a GCS score of 9-12.
9

Severe head injury is one that has a GCS score of 8 or less.

Examination of the pupils:

• Proper assessment of the

pupillary response requires
the use of a strong light
source and each pupil must
be assessed individually, with at least 10 seconds between assessments of
each eye to allow consensual responses to fade prior to stimulating the opposite
eye.
• A normal pupillary examination result consists of bilaterally reactive pupils that
react to both direct and consensual stimuli.
• Bilateral small pupils can be caused by narcotics, pontine injury (due to
disruption of sympathetic centers in the pons), or early central herniation (mass
effect on the pons).
• Bilateral fixed and dilated pupils are secondary to inadequate cerebral perfusion.
This can result from diffuse cerebral hypoxia or severe elevations of ICP
preventing adequate blood flow into the brain.
• Pupils that are fixed and dilated usually but not always indicate an irreversible
injury. If due to systemic hypoxia, the pupils sometimes recover reactivity when
adequate oxygenation is restored.
• A unilateral fixed (unresponsive) and dilated pupil has many potential causes. A
pupil that does not constrict when light is directed at the pupil but constricts
when light is directed into the contralateral pupil (intact consensual response) is
indicative of a traumatic optic nerve injury.
• A unilateral dilated pupil that does not respond to either direct or consensual
stimulation usually indicates transtentorial herniation.
• Unilateral constriction of a pupil is usually secondary to Horner syndrome, in
which the sympathetic input to the eye is disrupted and the pupil constricts due
to more parasympathetic than sympathetic stimulation. In patients with TBI,
Horner syndrome may be caused by an injury to the sympathetic chain at the
apex of the lung or a carotid artery injury.

Investigations

• Full blood count

• Bleeding time /clotting time if patient on anticoagulants
• Blood sugar
• Electrolytes including Serum creatinine
• X-ray skull to look for fractures if suspected

Indications for CT:

• Loss of consciousness for more than 10 minutes

• Skull fracture on X-ray or suspected on clinical grounds
• Basal skull fracture (haemo-tympanum, Raccoon’s sign (peri-orbital
ecchymosis or ‘panda’ eyes, cerebrospinal fluid otorrhoea, Battle’s sign,
Bleeding from the ear)
• GCS less than 13
• Post traumatic fit
• Focal neurological deficit
• Persisting vomiting
• Retrograde amnesia greater than 30 minutes
• Age more than 65 years of age, who are on anti-coagulation therapy

REFER BASED ON RED FLAGS

Immediate Referral- to a tertiary center (Guidelines I)

• Multiple injuries
• Cervical fracture
• GCS less than 9
• Fracture of the skull
• Battle’s sign (ecchymosis over the mastoid) and Raccoon’s sign(periorbital
ecchymosis) for fracture base of skull
• CSF rhinorrhoea or otorrhoea
• Neurological deficit
• Abnormal CT (Hematoma, fracture)
• Severe hypotension
• Abnormal pupils (constricted or dilated)

Other Management Guidelines:

Admission in a nursing home or a secondary care facility: (Guidelines II)
• Stable ABC wise
• Almost normal blood pressure/no bleeding
• History of loss of consciousness/confusion but less than 10 minutes
• No neurological deficit
• Pupils normal
• Retrograde amnesia present but less than 20 minutes
• If CT taken then should be normal
• Headache and vomiting present but less than 2-3 times
• Age above 65 years should always be admitted for observation
• Monitoring and managing protocol in a nursing home or a secondary
care facility- Guidelines III
• Elevate the head (not the head end of bed)
• Pulse/BP every 30 minutes
• Pupils every 15 minutes
• Orientation quiz every hour
 • Neurological examination including walking every hour
• Hemoglobin every hour
• Continous pO2 measurement if available
• Saline to keep the patient very well hydrated
• Sedatives if needed (should be short acting)
• Blood sugar and electrolytes once in 4 hours
Deteriorating signals - mandating referral to a tertiary centre Guidelines IV

Rapid pulse

Dropping BP

Pupillary abnormalities

Continous vomiting

Change in orientation

Seizures

CSF leak

Neurological signs like motor weakness or cranial nerve palsies
Discharge Guidelines V
• Fully conscious at 4 hours
• Oriented in time and place
• Loss of consciousness less than 10 minutes
• No retrograde amnesia
• No abnormal neurological signs
• Age less than 65
• CT if taken normal
Manage as outpatient if: Guidelines VI
• Fully conscious and no history of unconsciousness
• GCS 15
• No neurological signs
• Vomiting /headache subsided
• Patient has someone to can care for them
• Caregivers should be instructed to seek medical attention if patients develop
severe headaches, persistent nausea and vomiting, seizures, confusion or
unusual behavior, or watery discharge from either the nose or the ear.

• The patient should not exert himself/ herself, or consume alcohol/sedatives

 BURNS

Burns means thermal injury. It results in coagulate alteration of proteins due to wide
range of temperatures, ranging from the lowest - that is frostbite, to the highest -
that is electrical injury. Thus, both extremes of heat and cold can cause burn injury.

CAUSES OF BURNS:

Thermal or flame burns occur due to dry heat. Seventy five percent (75%) of
them occur at home and are preventable. The heat causes coagulation of the
protein in the tissue.

Scald burns are due to hot liquids, mostly in children while pulling down or
knocking hot liquids onto themselves, or by stumbling onto a burning agent.

Chemical burns are caused by strong acids and alkalis. These cause tissue
damage by penetration of the cell protein. Chemical burns are unique
because there is continuous tissue damage. The burns that occur at home
usually occur because of careless handling of the acid used for cleaning of
toilets. Homicidal burns are quite common in India; there are several cases
where young men whose advances are rejected by young women, act
criminally and throw acid on the woman’s face. Immediate removal of clothes
and continuous irrigation for at least 30 minutes with water is the most
effective measure of first aid management.

Electrical burns can be flash, arc or contact. The flash may ignite clothes and
hence burns may be superficial. In contact burns, the person comes in
contact with live wires. The current enters the body through nerves and
vessels and exits at another site.

PATHOPHYSIOLOGY
Burn Shock and Changes at the Vascular Level
Immediately following burns -

There is an increase in capillary permeability; this is due to inflammatory
mediators such as histamine, bradykinins, prostaglandins and leukotriens.

These mediators act by altering the membrane integrity in vessels leading to
leakage of fluid and protein from micro vessels.

When this fluid is lost into the skin, it appears as blisters if the skin is intact or
as exudates if the skin is lost.

When the fluid is lost in subcutaneous tissue, it causes edematous swelling.

Water holding lipid in the skin is destroyed, and four times the normal amount
of water is lost through skin. Increased water loss results in cooling of the
body and shivering, leading to additional heat expenditure.

All these result in the severe depletion of plasma volume with a marked
increase in the extra cellular fluid clinically manifested as hypovolemia.

Changes at the Cellular Level

In burn patients the cell membrane may become abnormal, allowing potassium to
leak out and sodium to enter. This condition is called Sick Cell Syndrome, which
occurs late in the shock period and is characterized by restlessness, disorientation
and over breathing. A 24-hour urine specimen shows a reversal of the sodium to
potassium ratio (normal approximately 2:1) Treatment is to correct hypoxia, correct
deficit of red blood cells by transfusion, administering insulin 150-200 units and 1-2
L of 5% glucose daily. This treatment seems to have a beneficial effect in restoring
the cell membrane to normal.

Changes at the Tissue Level

When there is injury to the tissue, metabolic acid substances are released into the
circulation. The severity of acidosis can be predicted as it is related to the amount of
tissue destruction. Decreased blood supply results in reduced tissue perfusion
leading to poor oxygen supply and retention of carbon dioxide eventually leading to
lactic acid production.

If well resuscitated with fluids, the capillary permeability recovers its tone, fluid is
reabsorbed and dieresis occurs. On the other hand, if not resuscitated well, the
patient goes into shock leading to decreased blood flow to various organs like the
kidney, heart, skin and intestine.

Decreased blood flow to the intestine results in paralytic ileus and vomiting.

Cardiovascular Response
Burns toxic substances such as potassium and enzymes that are toxic to
myocardium are elevated. The myocardium undergoes functional decompensation
during the acute phase and this continues during the stress period.

Renal
Oliguric Renal Failure

Hypovolemia following burn injury results in decreased renal perfusion
and
finally decreased urine output.

As in any trauma, increased ADH and aldosterone lead to increased
reabsorption of water and conservation of sodium resulting in
concentrated urine.

Increased amount of myoglobin and hemoglobin and other toxic products
decrease urine output.

Respiratory System:
In the hypovolemic shock phase, respiration becomes shallow and rapid due to
lactic acidosis. Inflammatory mediators from the burn wound can cause respiratory
distress symptoms.
Burn lung syndrome is insidious in onset. Manifests within 2-5 days and the first
symptom is increased respiratory rate, difficulty in breathing, rales and rhonchi.

Hematologic Changes
Altered capillary permeability allows loss of protein and electrolyte leading to hemo-
concentration. Anemia seen after burn injury at the end of the first week is due to

Red cell destruction as a result of injury

Damaged red cell agglutination, and inactivation by sledging
phenomenon

Accelerated rate of hemolytic from increased red cell fragility

Reduced nutrition leads to reduced hemopoietic production

Loss through wound donor site

Hemolytic associated with septicemia

Gastrointestinal System
Hypovolemia can result in splanchnic vasoconstriction leading to paralytic ileus.
Musculoskeletal System
The cell membrane gets damaged by burns and myoglobin is released from muscle
cells. Muscle wasting and osteoporosis may occur due to prolonged immobilization.

Immune System
Injury damages the skin barrier function. Suppression of both cellular and humoral
immunity leads to immunosuppression (ant) in burn victims.
1. Nonspecific – skin first line of defense
2. B-cell mediated humoral response.
Impaired cellular
lar immunity is suggested by lymphocytopenia, and delayed rejection
of allograft.

Metabolic Nutritional Response

Hypermetabolism results in

Increased oxygen consumption

Hyperglycemia

Decreased glucagons to insulin ratio

Protein catabolism

Negative nitrogen balance

Loss of weight.
Protein metabolism – Following burns the urinary nitrogen begins to increase in
levels of 2-3 times normal urinary excretion and the patient remains in negative
nitrogen balance which continues until wounds are closed. Since the main source of
this nitrogen appears to be from skeletal muscle, extreme muscle wasting can be
seen if protein and nitrogen losses are not adequately and vigorously replaced.
Low protein is also responsible for delayed healing and poor graft take.

Aggressive nutritional supplementation is a very strategic part of burn therapy.

Weight loss after major burns is

virtually inevitable unless aggressive
nutritional therapy is instituted soon
after the burn.

JACKSON’S ZONE OF INJURY

Zone of coagulation – When a patient is burnt, the tissue closest to the flame gets
the most thermal energy and varying amount of tissue gets coagulated. This tissue
is dead tissue.
Zone of stasis – There is a zone of tissue beyond the coagulated tissue which is
characterized by vascular stasis. This can be salvaged by good burn care but
exposure to
air and dehydration of this layer without skin cover prevents any recovery of this
zone as it undergoes desiccation and necrosis.
Zone of hyperemia – This zone shows minimal injury and recovers over a period of
7-10 days with prominent vasodilatation with increased blood flow.

Coagulation 1= Dead tissue

Stasis (Vascular) 2 = This
tissue can be salvaged if
infection is prevented.
Hyperemia 3 is tissue that
is fully viable.

Try to convert the zone of stasis

to a zone of hyperemia.

BURNS MANAGEMENT
The burn area should include the areas that have blisters and areas that are red
and inflamed. The following line diagram will help as guide and can be used as
chart record. In children, because of a larger head and smaller limbs the calculation
changes.

ADULT 18%
CHILD
9% BACK

19%
9% 9%
18%

9% 36% 9%
Front &
Back

1%

18% 18%
13% 13%

Management of burns – an outline

• Stop the burning
• ABCDE
• Determine extent of burns
• Good IV access
• Early fluid replacement
• Provide analgesia
• Prevent hypothermia
The main priorities in burn management are:
Airway
Breathing
Circulation
(D&E)
Analgesia
Infection control

Mortality owing to burns injuries can be classified as:

a) Early death: In the early stage, death from burns occurs due to airway
obstruction, respiratory failure and / or shock.
b) Late death: can occur because of renal failure, sepsis and / or multi-organ
failure.
When assessing the severity of a burns injury, one has to look at:
a) the degree or depth of the burn
b) the percentage of the body are affected
c) the type of burn i.e. its source
The prognosis for the burns patient will depend on the severity of the burn as well
other factors including:
− whether there is any other injury
− whether the patient abuses alcohol or drugs.

The degree or depth of the burn

 In superficial or first degree burns, there is pain and erythema but no
blisters.
 Partial thickness or second degree burns are painful, with blisters and
weeping sores; the skin has a mottled appearance.
 Full thickness or third degree burns are painless. The burnt portion is
either white or dark and leathery.
In early resuscitation, the depth of the burn is less important than the surface area
covered (size) of the burn.
FLUID CALCULATION
First 24 hours- Burn requirement + Wt.in Kgs. x % of burns x 2
Plus normal requirement = 2500 ml
(Normal requirement to compensate for loss through lungs -500 ml, skin-500 ml,
urine -1400 ml, feces=100 ml) insensible loss
(Example – A 30 year old woman has flame burns that cover 50% of her body
surface. If her weight is 50 kgs, calculate the fluid requirement for the first two days.
Burn requirement is 50 kg x 50% x 2=5000 ml
Normal requirement is – 2500 ml/day
Total= 7500 ml).

3750 ml should be given in the first 8 hours and the rest should be
given in the next 16 hours. The first 8 hours means the time from the
onset of burns and not the time of admission.

Second 24 –hours
Burn requirement = 5000 ml (Half given as colloid and half as crystalloid)
Normal requirement = 2500 ml

Third 24 –hours:
Only normal requirement:
5% D/S 2000ml plus N/S 500ml + In Kcl 3gms

In burns involving more than 50% body surface area, the capillary permeability is at
its maximum thus affecting both treatment and prognosis. Hence calculation should
be for 50% only even if the burns are over 50%.
Fluid calculation is only a basic guideline. The best guideline is hourly urine output
of 0.5-1ml/kg body weight/hour. Catheterize the patient and adjust the IV fluids
according to urine output.

After 18-24 hours, capillary integrity generally returns and fluid administration
should be decreased, following resuscitation. At this point, colloid administration is
useful, generally plasma or blood or 5% albumin (the latter is more expensive).

First aid do’s and don’ts

Do’s Don’ts
Remove from site …wash with dirty water
Arrange transfer …cover with blankets directly on the burn
wound
Apply non-occlusive silver sulphadiazine …burst blisters
dressing
IV access
Analgesic and sedation
Tetanus prophylaxis
Antibiotics

Adult burns of less than 15% TBSA are

usually not enough to initiate a
generalized capillary leak, and these
patients can be rehydrated successfully
primarily via the oral route with modest IV
fluid supplementation.
Determining the depth of the wound
wound-

Burn depth can be classified into 4 categories:

These include

Superficial (first-degree)
degree) burns,

Partial-thickness
thickness (second
(second-degree) burns,
o Superficial
o Deep

Full-thickness
thickness (third
(third-degree) burns, and

Burns extending beyond the skin (fourth degree)

Superficial (first-degree)
degree) burns are limited to epidermal layers and are equivalent to
superficial sunburn without blister formation.

Partial-thickness (second--degree) burns are also called dermal burns and can be
superficial partial-thickness
thickness burns or deep partial thickness burns.

Superficial partial-thickness
hickness burns: Involve the

o Superficial papillary dermal elements and are

o Pink and moist with
o Exquisite pain upon examination.
 o Blister formation may appear. This type of burn is expected to
heal well within several weeks, without skin grafting

Deep partial-thickness burns involve the whole dermis. They can have
a variable appearance ranging from
o Pink or white with a dry surface.
o Sensation may be present but is reduced, and capillary refill is
sluggish or absent.
o If this gets infected, it gets converted to 3rd degree burns

Full-thickness (third-degree) burns
o The whole of the dermis is involved
o Appears white, brown or black.
o White or leathery surface
o Painless

Fourth-degree burns are full-thickness burns that extend into muscle
and bone.

Summary- Adapted from Dermnet NZ

Classification Signs and symptoms

• Involves only the epidermis

Superficial or first • May be painful, red and warm, no blisters, moist

degree burn
• Blanching on pressure (turns white)

Partial thickness or
second degree burn
• Involves the epidermis and some portion of the dermis
• Depending on the how much of the dermis is affected the burn
is further broken down into superficial or deep
• Superficial partial thickness burns are usually painful, red,
moist, with blisters, hair still intact

• Deep partial thickness burns may or may not be painful (nerve

endings destroyed), may be moist or dry (sweat glands
destroyed), hair is usually gone
Full thickness or third • Most severe burn and involves all layers of skin – epidermis
degree burn and dermis
• Nerve endings, small blood vessels, hair follicles, sweat
glands are all destroyed

• Burns are painless with no sensation to touch, skin is pearly

white or charred, dry and may appear leathery
Fourth degree burns • Subcutaneous fat tissue, muscle and bone may also be
involved in very severe burns

BURN WOUND MANAGEMENT

Burns less than 15% in adults and 10% in children can be safely managed by the
private practitioner.

All others may be referred or admitted in their nursing homes provided some
expertise in burn management is available. In any case, they must have a large
bore IV access needle in place and Ringer lactate should be started before referral.

The components of burn wound management are:

• Wound cleansing
• Choice of topical dressing
• Pain control
• Early return instructions

Superficial burns Burn

managed in ancare
wound outpatient setting presents a low risk of
infection; thus, a clean rather than sterile technique is reasonable.

You can help patients clean the burn with lukewarm tap water and mild soap.

Rupture blisters if any and put back the skin as a biological cover.

Gently clean the wound of debris and exudate on a regular basis.

This usually requires daily removal of accumulated exudate and topical
medications.

Soaking dressings in lukewarm tap water may decrease the pain associated
with their removal.

Use 1% Silver Sulphadiazine ointment and provide a padded occlusive
dressing.

Gently cleanse the wound with a gauze or clean washcloth, inspect for signs
of infection, pat dry with a clean towel, and re-dress the patient.
Wound dressing, should provide 4 benefits, including:

(1) Preventing dryness of the wound which can convert a 2nd degree into a 3rd
degree wound. This can be done by using an agent which is viscous like Silver
Sulphadiazine.

(2) Preventing infection: This can be done by using a powerful anti bacterial agent
and also by an occlusive agent. Again infection can convert a 2nd degree into a 3rd
degree wound.

(3) Pain control: This is usually not a problem between dressings; however during a
dressing some patients have a lot of pain and an opiate analgesic capsule like
Proxyvon may be given 2 hours before dressing.

(4) Prevention of trauma to the wound: This is usually achieved by a padded

occlusive dressing.

Suggested topical agents for burn wound dressing

Silver sulphadiazine-1%
Non-staining, painless, good Gm+ve and Gm-ve cover, limited antifungal cover
with intermediate penetration of eschar
However, prevents epithelialization and causes reversible leucopenia (10%)

Neosporin
Used on face, as is non toxic to eyes and non-staining

Betadine (1%Povidone Iodine)
Good spectrum, painful, iodine toxicity, metabolic acidosis

Sulfamylon (Mafenide 10%)
Good spectrum, penetrates eschar & cartilage
Painful, prevents epithelialization & causes metabolic acidosis.
Treatment of blisters is controversial. De-roofing the blister, removing the fluid and
retaining the skin is important as the blister fluid contains inflammatory mediators
such as thromboxane, known to be detrimental to the microcirculation in the zone of
statis. Best to rupture the blister, remove the fluid and retain the skin as a biological
cover.

Nutrition:

Burns set in motion a high catabolic rate, and calorie deficit increases the chances
of infection; one reason why burns patients often die of septicemia. Hence
aggressive nutritional supplementation is very important.

Since as family medicine practitioners, you are likely to treat mainly patients with
less than 15% burns, you do not need to insert a NG tube to forcefeed.

However you will have to prescribe a very high calorie diet, vitamins and minerals
so that you compensate for the high catabolism.

SPECIAL INDICATIONS FOR REFERRAL:

Circumferential limb burns and the leathery eschar produce chest constrictions and
compartment syndromes in the extremities or distal ischemia and necrosis.
Immediate escharotomy /fasciotomy should be performed in the mid lateral lines of
the affected extremities and the fingers.
Keep arm elevated during referral.
Doppler will confirm ischemia. Therefore circumferential burns are an indication for
referral.

EVIDENCE OF WOUND SEPSIS IS AN INDICATION FOR REFERRAL as

evidenced by a change in the patient’s general condition or a change in the wound
status:
Change in the patient’s general condition may be obvious like

Hypotension

Tachypnoea

Increased fever

Tachycardia

Hypo or hyperglycemia

Paralytic ileus

Altered mental state, hypoxia, hypothermia

Decreased urine output

Change in the wound status:

Wound may be soft with surrounding cellulites. The initial bacterial danger is
due to beta hemolytic streptococci. The rich vascularity of the inflammatory
phase, edema and neutralization of the bacterial defense mechanism of
sebum - all render the burn wound prone to streptocococcal invasion.

Purulent discharge may be present.

Healthy granulation tissue may deteriorate.

Either of the above are indications for referral.

Immediate action for flame burns:

STOP the source of fire if possible
DROP: Lie
ROLL: Roll on the ground and do not run.
COOL: Pour cold water over the burning garment.

DON’T MISS THE AIRWAY BURN

Check carefully for an airway burn in the following cases:
 If the burn occurred in an enclosed place.
 If there are facial burns or singed nasal hair.
 If there is ash in the sputum.
 If the voice is hoarse or if there is cough or stridor.
  If there are circumferential, full thickness burns of chest or neck.
N.B. Absence of a facial burn does not rule out the possibility of significant upper
airway injury. Respiratory involvement may only present after 24 hours.
Consider early intubation if the patient has:
 Increasing hoarseness
 Difficulty in swallowing secretions
 Increasing respiratory distress
OR
 if the patient needs to be transferred.
Intubation may be more difficult if delayed. Suspect cervical injury if in motor
vehicular injury / blunt trauma.

The signs of smoke inhalation injury include severe bronchospasm, alveolar

damage and pulmonary oedema. It may be caused by superheated air, steam or
chemicals or carbon monoxide. Carbon monoxide causes carboxy haemoglobin to
be formed. The treatment for this is oxygen supply and mechanical ventilation.
Cyanide poisoning results in tissue asphyxia and metabolic acidosis. The treatment
is oxygen supply, mechanical ventilation and sodium thiosulphate.

Cricothyroidotomy or tracheosomy may be required in case conventional methods

fail or if there is inadvertent tracheal extubation.

ELECTRICAL AND CHEMICAL BURNS

Electrical burns are complex injuries and may affect multiple organs. Most tissue
damage is caused by heat generated by current flow leading to progressive loss of
viable tissue due to delayed thrombosis of microvasculature.
CLASSIFICATION
• Low voltage <1000 volts causes local tissue necrosis
• High voltage >1000 voltage causes deep muscle injury and fractures
• Ultra high voltage seen in lightening injury, blast injury resulting in cardiac
arrest
TYPE OF INJURY
Electrical burns damage tissues in 3 ways – Flash, Arc or Contact
Contact burns are the commonest type of injury. This occurs due to contact with a
high voltage system converting electrical energy into heat resulting in tissue
damage. The current enters, traverses the body and exits at another site. The final
damage depends on the pathway of the current through the body.
Flash burns – The flash sets the clothing on fire and burns are usually superficial
and heal spontaneously.
Arc burns give rise to localized deep burns due to the intense heat on the
termination of current flow. The current exists and re-enters skin over a fixed joint to
find the shortest pathway commonly seen on flexor surfaces of the body.
PATHOPHYSIOLOGY OF SYSTEMIC CHANGES
As the current passes through the tissues, heat is generated because tissue is not a
perfect conductor and acts as a resistance. Blood vessels and nerves are good
conductors of current, while dry skin and bone are poor conductors.
Heart: Immediately after electric shock patient may go into cardiac arrest or develop
arrhythmias.
Vascular: Thrombosis of major vessels causing ischemic symptoms.
Kidneys:
Due to vascular endothelial damage there may be occlusion, thrombosis and
progressive ischemic necrosis of the muscles. A crush type of syndrome is seen in
the presence of significant amount of dead muscle, and this poses a risk of renal
failure with the precipitation of muscle breakdown products like myoglobin and
hemoglobin. If myoglobinuria persists for more than 6 hours, it is a sign of major
muscle loss requiring amputation or debridement.
CNS and peripheral nervous system: Loss of consciousness, paresis, hemiplegic
or paraplegia.
Limbs: Compartment syndrome due to swollen necrosed muscles.

CLINICAL FEATURES of electrical burns:

Depends on mode of injury and duration of contact.
If the patient has been thrown, or has had a fall, internal injury and fracture should
be suspected and excluded.
Cardiac arrest, shock, paralysis, unconsciousness are all possibilities.
Resuscitation- Calculating IV fluids is difficult in electrical burns but the aim should
be to clear the pigments like myoglobin and hemoglobin; some advocate 7ml/kg/%
of
burns. It is important to maintain adequate organ tissue perfusion. If adequate fluids
are not given, the chances that the patient would have renal failure is high. This is
because the pigments are breakdown products of dead muscle, and can lead to
damage of the kidneys.

MANAGEMENT
Emergency first aid:
. Disconnect from electrical supply by switching off the power as early as possible.
. Rescue – Caution must be exercised by the rescuer so that he does not become a
part of the electrical circuit in attempting to free a person still in contact with the live
wire.
. Use dry wood and push the victim away from current source. (Please note: if while
the power is on, an attempt is made to remove the person it can be dangerous to
the rescuer as the current can arc as he approaches the victim.)
. Cardiac and respiratory status are assessed, ECG should be taken to check
arrhythmias.
. Start intravenous fluids and then take the patient to hospital for further
management.

Chemical burns:
A chemical burn is unique because the chemical continuously damages tissue till it
is completely washed off or neutralized. Chemical injury may be accidental or
homicidal. The extent of damage is directly proportional to its concentration,
volume and the duration of contact. Chemical burns generally involve the face and
eyes. The color of the skin is dark brown and black. The eschar appears dry,
adherent and insensitive to touch.
Chemical injury usually involves people at home, industrial workers and those who
are involved in chemical warfare. In chemical burns, although the extent of injury is
small, the destruction and deformity are severe.

FIRST AID MANAGEMENT

Immediately remove all clothes and start continuous copious irrigation with water for
at least 30 minutes. Then refer for early excision surgery.
Early excision surgery is necessary as spontaneous eschar separation is delayed
due to late development of subeschar infection.
Eye burns should be irrigated with water for a prolonged period of time and an
ophthalmologist should be called in as early as possible for expert opinion to
prevent blindness.
 BURNS
ALGORITHM

Special regions:
Adult more than
Child more than Perineum, face
15%
10% or genitals or
burns
circumferential
burns

Yes: Then refer Yes: Refer after No

No Refer for
after IV access IV access
Doppler &
escharotomy for
circumferential
Rule out homicidal burns burns. Rest need
Cigarette burns especially in women admission and
suspect child abuse dressing.

Burn wound care

See below
Immunization
Hydration and high calorie
nutrition

Superficial burns managed in an out

patient setting presents a low risk of
st nd infection, thus, a clean rather than sterile
1 and 2 degree
superficial burns should technique is reasonable.
heal easily without
Clean the burn with lukewarm tap water
grafting and without and mild soap.
scarring.
Rupture blisters if any and put back the
skin as a biological cover.

Gently clean the wound of debris and
exudate on a regular basis.

This usually requires daily removal of
nd
accumulated exudate and topical
2 degree deep may medications.
also heal without
Soaking dressings in lukewarm tap water
grafting if no infection may decrease the pain associated with
their removal.

Use 1% Silver Sulphadiazine ointment and
provide a padded occlusive dressing.

Gently cleanse the wound with a gauze or
rd
clean washcloth, inspect for signs of
3 degree when it is infection, pat dry with a clean towel, and
clean & granulates refer re-dress the patient.
for skin grafting (Burn wound care)
 ANAPHYLAXIS1

An anaphylactic reaction or anaphylaxis is an exaggerated immunological

response to a substance to which an individual has become sensitised. When the
patient is in contact with the substance, histamine, serotonin, tryptase and other
vasoactive substances are released from basophils and mast cells. Anaphylactoid
reactions are clinically indistinguishable from anaphylaxis, but are mediated by
the drug or substance directly, and not by sensitised IgE antibodies.

Direct release of small amounts of histamine is commonly seen with drugs such as
morphine and non-depolarising muscle relaxants (tubocurare, alcuronium, atracurium).
Clinical manifestations are usually minor and consist of urticaria (skin redness and
swelling), usually along the line of the vein, flushing and occasionally mild
hypotension.

Any drug can potentially cause an allergic reaction but agents used in anaesthetic
practice that have been implicated in producing anaphylactic reactions include
thiopentone, suxamethonium, non-depolarising muscle relaxants, ester local
anaesthetics, antibiotics, plasma expanders (dextrans, starches and gelatins) and latex.

Clinical Presentation of Anaphylaxis

The commonest features are cardiovascular. Not all signs occur in every patient - one
feature may be more obvious than others. Reactions range from minor to life-
threatening. An awake patient will have a range of symptoms, but the diagnosis is
more difficult in an anaesthetised patient.

Suspect anaphylaxis in an anaesthetised patient who suddenly becomes

hypotensive or develops broncho-spsm, particularly if this follows administration of a
drug or fluid. Latex allergy may be delayed in onset, sometimes taking up to 60
minutes to occur.

• Cardiovascular. Hypotension and cardiovascular collapse. Tachycardia,

arrhythmias, ECG may show ischaemic changes. Cardiac arrest.
• Respiratory System. Oedema of the glottis, tongue and airway structures may
cause stridor and airway obstruction. Bronchospasm – may be severe.
• Gastrointestinal. There may be abdominal pain, diarrhoea or vomiting.
• Haematological. Coagulopathy.
• Cutaneous. Flushing, erythema, urticaria.

MANAGEMENT
Immediate Treatment of a Severe Reaction
• Stop administration of the causal agent and call for help.
• Follow the ABC of resuscitation.
• Adrenaline is the most useful drug for treating anaphylaxis as it is effective in
bronchospasm and cardiovascular collapse.

A - Airway and Adrenaline

• Maintain airway and administer 100% oxygen.

• Adrenaline. If I/V access available give 1:10,000 adrenaline in 0.5-1ml
increments, repeated as required. Alternatively give i/m 0.5 - 1mg (0.5 - 1ml of 1:
1000 solution) repeated each 10 minutes as required.

B - Breathing

• Ensure adequate breathing. Intubation and ventilation may be required.

• Adrenaline will treat bronchospasm and swelling of the upper airway.
• Nebulised bronchodilators (e.g. 5mg salbutamol) or I/V aminophylline may be
required if bronchospasm is refractory (loading dose of 5mg/kg followed by
0.5mg/kg/hour).

C - Circulation

• Assess the circulation. Start CPR if cardiac arrest has occurred.

• Adrenaline is the most effective treatment for severe hypotension

• Insert 1 or 2 large bore I/V cannulae and rapidly infuse normal saline. Colloid
may be used (unless it is thought to be the source of the reaction).
• Venous return may be aided by lifting the patient's legs or tilting the patient
head down.
• If the patient remains haemodynamically unstable after fluids and adrenaline -
give further doses of adrenaline or an intravenous infusion (5mg in 50mls saline
or dextrose 5% through a syringe pump, or 5mg in 500mls saline or dextrose
5% given slowly by infusion). Uncontrolled intravenous boluses of adrenaline
can cause dangerous surges in blood pressure and arrhythmias. Give the drug
carefully, observing the response and repeating when required. Try to monitor
the ECG, blood pressure and pulse oximetry.

Intramuscular dose of adrenaline in children

> 5 years 0.5ml of 1:1000

4 years 0.4ml of 1:1000

3 years 0.3ml of 1:1000

2 years 0.2ml of 1:1000

1 year 0.1ml of 1:1000

Further Management

• Give antihistamine agents. H1 blockers eg chlorpheniramine (10mg i/v) and H2

blockers ranitidine (50mg i/v slowly) or cimetidine (200mg i/v slowly).
• Corticosteroids Give hydrocortisone 200mg i/v followed by 100-200mg 4 to 6
hourly. Steroids will take several hours to work.
• Make a decision whether to cancel or continue with proposed surgery.
• Transfer the patient to a high care area (eg intensive care or high dependency
unit) for further observation and treatment. Anaphylactic reactions may take
several hours to fully resolve and the patient must be closely observed during this
time.

Less severe reactions

Anaphylaxis sometimes results in less severe reactions which are not life threatening.
Treatment is similar to the regime above, but i/v adrenaline may not be required.
Manage the ABC as described, and assess the response. Drugs such as ephedrine or
methoxamine may be effective to treat hypotension along with i/v fluids. However,
whenever the patient's appears to be worsening, always use adrenaline.

Diagnosis and Investigations

Diagnosis is made on clinical grounds - though it may not be possible to define exactly
which agent precipitated the attack. Make a record of events in the notes and when
appropriate inform the patient and his/her general practitioner. If the patient requires
further anaesthesia or surgery avoid the use of the suspected precipitating agents.

Some specialised laboratories can estimate Tryptase (a breakdown product of histamine)

which can help to confirm the diagnosis. Take blood into glass tubes 60 minutes after the
reaction. This test is unavailable in many places.

DROWNING
Drowning is a leading preventable cause of unintentional morbidity and mortality.
Although this chapter focuses on treatment, prevention is possible, and pool fencing
has been shown to reduce drowning and submersion injury (Class I).The most
important and detrimental consequence of submersion is hypoxia. Therefore,
oxygenation, ventilation, and perfusion should be restored as rapidly as possible.
This will require immediate bystander CPR plus immediate activation of the
emergency medical services (EMS) system. Victims who have spontaneous
circulation and breathing when they reach the hospital usually recover with a good
outcome. Victims of drowning may develop primary or secondary hypothermia. If
the drowning occurs in icy (_5°C [41°F]) water, hyp othermia may develop rapidly
and provide some protection against hypoxia. Such effects, however, have typically
been reported only after submersion of young victims in icy water. All victims of
drowning (see definitions below) who require any form of resuscitation (including
rescue breathing alone) should be transported to the hospital for evaluation and
monitoring even if they appear to be alert with effective cardiorespiratory function at
the scene. The hypoxic insult can produce an increase in pulmonary capillary
permeability with delayed onset of pulmonary complications.

Definitions, Classifications, and Prognostic Indicators

A number of terms are used to describe drowning. To aid in the use of consistent
terminology and the uniform reporting of data from drowning, the Utstein definition
and style of data reporting are recommended.
Drowning. Drowning is a process resulting in primary respiratory impairment from
submersion/immersion in a liquid medium. Implicit in this definition is that a liquid/air
interface is present at the entrance of the victim’s airway, preventing the victim from
breathing air. The victim may live or die after this process, but whatever the
outcome, he or she has been involved in a drowning incident. A victim may be
rescued at any time during the drowning process and may not require intervention
or may receive appropriate resuscitation measures. In either case the drowning
process is interrupted. The Utstein statement recommends that the term
neardrowning no longer be used. It also de-emphasizes classification based on type
of submersion fluid (salt water versus fresh water). Although there are theoretical
differences that have been reported in laboratory conditions, these have not been
found to be clinically significant. The most important factors that determine outcome
of drowning are the duration and severity of the hypoxia. Although survival is
uncommon in victims who have undergone prolonged submersion and require
prolonged resuscitation, successful resuscitation with full neurologic recovery has
occasionally occurred with prolonged submersion in icy water. For this reason,
scene resuscitation should be initiated and the victim transported to an ED unless
there is obvious physical evidence of death.

Modifications to Basic Life Support for Drowning

No modification of standard BLS sequencing is necessary. Some cautions are
appropriate, however, when beginning CPR for the drowning victim.
Recovery From the Water
When attempting to rescue a drowning victim, the rescuer should get to the victim
as quickly as possible, preferably by some conveyance (boat, raft, surfboard, or
flotation device). The rescuer must always be aware of personal safety. Recent
evidence indicates that routine stabilization of the cervical spine is not necessary
unless the circumstances leading to the submersion episode indicate that trauma is
likely (Class IIa). These circumstances include a history of diving, use of a water
slide, signs of injury, or signs of alcohol intoxication. In the absence of such
indicators, spinal injury is unlikely. Manual cervical spine stabilization and spine
immobilization equipment may impede adequate opening of the airway, and they
complicate and may delay the delivery of rescue breaths.

Rescue Breathing
The first and most important treatment of the drowning victim is the immediate
provision of ventilation. Prompt initiation of rescue breathing increases the victim’s
chance of survival. Rescue breathing is usually performed when the unresponsive
victim is in shallow water or out of the water. If it is difficult for the rescuer to pinch
the victim’s nose, support the head, and open the airway in the water, mouth-to-
nose ventilation may be used as an alternative to mouth-to-mouth ventilation.
Untrained rescuers should not try to provide care while the victim is still in deep
water.
Management of the drowning victim’s airway and breathing is similar to that
recommended for any victim of cardiopulmonary arrest. There is no need to clear
the airway of aspirated water, because only a modest amount of water is aspirated
by the majority of drowning victims and it is rapidly absorbed into the central
circulation, so it does not act as an obstruction in the trachea. Some victims aspirate
nothing because they develop laryngospasm or breath-holding. Attempts to remove
water from the breathing passages by any means other than suction (e.g.
abdominal thrusts or the Heimlich maneuver) are unnecessary and potentially
dangerous. The routine use of abdominal thrusts or the Heimlich maneuver for
drowning victims is not recommended.
Chest Compressions
As soon as the unresponsive victim is removed from the water, the rescuer should
open the airway, check for breathing, and if there is no breathing, give 2 rescue
breaths that make the chest rise (if this was not done in the water). After delivery of
2 effective breaths, the lay rescuer should immediately begin chest compressions
and provide cycles of compressions and ventilations. The healthcare provider
should check for a central pulse. The pulse may be difficult to appreciate in a
drowning victim, particularly if the victim is cold. If the healthcare provider does not
definitely feel a pulse within 10 seconds, the healthcare provider should start cycles
of compressions and ventilations. Only trained rescuers should try to provide chest
compressions in the water. Once the victim is out of the water, if the victim is
unresponsive and not breathing (and the healthcare provider does not feel a pulse)
after delivery of 2 rescue breaths, rescuers should attach an AED and attempt
defibrillation if a shockable rhythm is identified.

Vomiting by the Victim During Resuscitation

The victim may vomit when the rescuer performs chest compressions or rescue
breathing. In fact, in a 10-year study in Australia, two thirds of victims who received
rescue breathing and 86% of victims who required compressions and ventilations
vomited. If vomiting occurs, turn the victim’s mouth to the side and remove the
vomitus using your finger, a cloth, or suction. If spinal cord injury is possible, logroll
the victim so that the head, neck, and torso are turned as a unit.

Modifications to ACLS for Drowning

The drowning victim in cardiac arrest requires ACLS, including early intubation.
Every drowning victim, even one who requires only minimal resuscitation before
recovery, requires monitored transport and evaluation at a medical facility. Victims
in cardiac arrest may present with asystole, pulseless electrical activity, or pulseless
ventricular tachycardia/ventricular fibrillation (VF). Follow the guidelines for pediatric
advanced life support and ACLS for treatment of these rhythms. Case reports
document the use of surfactant for fresh water–induced respiratory distress, but
further research is needed. The use of extracorporeal membrane oxygenation in
young children with severe hypothermia after submersion is documented in case
reports. There is insufficient evidence to support or refute the use of barbiturates,
steroids, nitric oxide, therapeutic hypothermia after return of spontaneous
circulation, or vasopressin.

Improving Neurologic Outcomes: Therapeutic Hypothermia

Recent randomized controlled trials (LOE 1) and (LOE 2) and subsequent
consensus recommendations support the use of therapeutic hypothermia in patients
who remain in a coma after resuscitation from cardiac arrest caused by VF and note
that it may be effective for other causes of cardiac arrest. However, the
effectiveness of induced hypothermia for drowning victims has not been
established, and evaluation of this approach is warranted. The 2002 World
Congress on Drowning recommended further studies to identify the best treatments
for drowning victims.
Summary
Prevention measures can reduce the incidence of drowning, and immediate, high-
quality bystander CPR and early BLS care can improve survival. Rescue breathing
should be provided even before the victim is pulled from the water if possible.
Routine stabilization of the cervical spine is not needed. Further studies are
necessary to improve neurologic outcome for drowning victims.

MASS CASUALTIES AND TRIAGE

When there are mass casualties, the scene is often chaotic with people shouting
and crying, a lot of blood and broken bones and people coming in to help adding to
the confusion. The silent child who is not breathing, someone with a head injury or
airway obstruction is often overlooked.
A Life Support plan in this situation mandates a Triage or ‘sorting out’.
- Identify a leader – most often it will be you!
- Find at least 2 helpers. If they have even some basic training they will be of help to
you.
- Make 3 rounds so as to assess, treat and not miss an injury. Walk with your
helpers to each patient not taking more than 2min / patient for each round.
Round 1 – Open airway and stop bleeding.
- Check the airway. Institute chin lift, jaw thrust and place in recovery
position depending on the patient’s condition. Leave one helper with
any victim who has airway problems. Give him clear instructions on
management and tell him to shout for you if he has any problems
maintaining the airway.
- Stop external bleeding if any. Instruct bystander to apply pressure on
proximal artery and elevate the limb. Keep victims warm.
Round 2 – Start IV infusions and pain relief.
- Start IV infusions if peripheri (limbs) or tip the nose are cold or the
pulse is feeble and thready. Do not waste time trying to take blood
pressure.
- Pain relief: A single dose of ketamine (0.2-0.3 mg/kg)
Round 3 – Find out which patient needs immediate further care.
- During this round, sweep off blood and dirt and make a careful
assessment.
- Is the patient so severely injured that he will not make it even with the
best care?
- Oes this patient have a serious injury but will not die from it? – Save
him and label him Patient no.1.
Patient no.1
- Reassess.
- Secure airway, stabilize neck.
- Check breathing, insert chest drain if necessary.
- Circulation - Has the IV infusion proved effective? Is more required?
Have you sent blood for cross matching? Immobilze fractures and
apply compressive dressing.
- Prepare Patient no.1 for transfer / evacuation.
Patient no.2 – Assess and proceed as you did for Patient no.1.
When all patients are as stable as you can get them, start the evacuation.
Remember that the patient who shouts the loudest is often the one who needs the
LEAST care!

Documentation is vitally important both for further management of the patient and
for legal purposes. The scene is often chaotic but do document relevant history and
vital signs as soon as you can along with the details of the management you have
instituted. Note the time and date on your documents!
Transport: Give clear instructions for the evacuation of each patient. (Pin your
instructions and documentation to their clothes if necessary.) Note the position, IV
fluidsand drugs they may be given during transport and try and stay with the sickest
patient yourself.
In short: Prepare yourself well. Keep cool as management of mass casualties is a
difficult task.
Work systematically. Complete rounds 1 and 2 before you start round 3 and
identify ‘Patient no.1’.
REFERENCES

1. Christopher M, Albin Immanuel, Verghese Cherian, Rebecca Jacob.

Anaphylaxis, Adapted from Update in Anaesthesia No 12. Pg 71
2 . Hans Husum, Mads Gilbert, Torben WIsborg. Save Lives, Save Limbs, pg 70

INSTRUCTION SHEET – PRIMARY TRAUMA CARE (MODULE 4.1)

1. This booklet has three modules

2. The joint TMA is at the end of Module 4 - 3 and covers the portions of all
three modules.
3. After you complete the module, tear out:
(a) Tutor marked assignment (in Module 4-3);
(b) Three module evaluation forms (at the end of each Module - 4-1, 4-2
and 4-3)
4. Student’s timesheets, if you have been able to record your timings (See
enclosed letter) and enclose them in the envelope .Write your name and roll
number on the tutor marked assignment and take a photocopy before
dispatching it.
Kinds of injury:
When the stationary head is hit by a moving object, acceleration is imparted to it and the
injury is called accelerative injury. When the moving head is suddenly brought to a halt as in
a moving car that has been hit, decelerative injury occurs. Two mechanisms of brain injury
are operative:

Coup and contre coup injury and

Rotational or Shearing injury

Coup and contre

contre--coup injury: Imagine a situation where the head has been hit as a
moving car has hit a tree (decelerat
(decelerative
ive injury). The skull suddenly comes to halt; the brain in
it does not immediately, but continues to move forwards. It hits the anterior sections of the
skull (anterior and middle fossa) violently and then rolls backwards and hits the posterior
part of thee skull. The direct hit (in this case anterior parts of the brain) is called the “coup”
injury and the indirect injury (in this case posteriorly) is called
the “contre coup” injury.

The anterior parts of the brain that is injured

are usually the frontal and temporal lobes Rough places (arrows)
and especially those parts of the lobe that contuse
abut against rough prominent portions of the the brain.
skull. The occipital lobe posteriorly is not
usually injured as badly, since the posterior
cranial fossa is smooth.

This then is how the contusions in the brain

occur. They can bleed and produce a “mass
lesion” that can greatly increase the ICP and
be life threatening.

Shearing or rotational injury:

When the brain moves forwards and backwards after impact, it is

held at its centre tightly by the brainstem. A rotational force
(torque) occurs and axons in the white matter in the brain gets
stretched. If they only stretch without breaking, then concussion
Rotational injury results. The patient loses consciousness shortly for seconds or
minutes or sometimes hours and then
Head injury
Abhijit : This is the CT picture. What do you see?

IV. a) What does this CT of a patient with headache and dizziness show? He had a history of
a minor head trauma.

b) What are the strategies to reduce the increase