Emergencies in Orthopaedics John Ebnezar
Chapter Notes

Save Clear

General Principles of EmergenciesChapter 1

It is a serious situation needing prompt action (Fig. 1.1).
Golden Hour
Managing an emergency within the first 60 minutes of the injury is crucial and will determine the outcome of the injured whether it is road to recovery or doom to mortuary. This is called the golden hour and was first mooted by Dr. R Adams Cowley. In this book an attempt is made to outline various measures one needs to take in this critical Golden hour.
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Fig. 1.1: Emergency is a serious situation
Orthopaedic Emergency
It is a serious Orthopaedic situation needing prompt action (Situation is serious, it need not be always life threatening).
Accidental Events how does it Happen?
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Fig. 1.2: Emergencies in life strike suddenly
  • Unfavorable circumstances
  • Medical help is not available
  • No training to handle emergencies
  • Afraid of medicolegal problems.
Action in an Emergency
  • Do not panic
  • Should be immediate
  • No time to dither
  • No time to wait
  • Cannot wait till a doctor arrives or reach the victim to a hospital (It may be too late).4
When Emergency Strikes, Do not Panic! Oh How Can I forget GV Atri
What does Panic do?
  • It paralyses the mind
  • It paralyses the judgment
  • It paralyses the muscles
  • It creates uncontrollable fear
  • Poses a great threat to the safety of you and the victim
  • It converts a problem into a tragedy.
Antidote: Knowledge alone overcomes panic!
The Poignant Story Of Mr G V Atri
GV Atri was a very famous playback singer of Karnataka. He was young, dynamic, talented and a very good show organizer. After a late night music program in a Coastal belt of Karnataka, he along with his family members went for a recreational bath by a river side the next morning. He was blissfully unaware of the tragic event that was to follow.
While his wife, her sister and children were taking bath in the river, Atri carrying his toddler son in his arms watched them play and enjoy from the river bed. Suddenly he noticed his sister in law's daughter being dragged deep inside the river by a painful under water current. Seeing her scream her lungs out her mother held her daughter's hand and tried to pull her out. But the powerful undercurrent dragged both of them inwards and they started to drown. Atri's wife rushed to their rescue and tried to pull them out. Unfortunately she was also dragged towards the current.
Atri watched in horror his family members being serially dragged by the vicious current. Instead of 5remaining calm and trying to explore the possible ways to help them, he panicked and got into the water holding his son in his arms and drowned with all his family members. He did not even have the presence of mind to at least leave his son on the river bank! Thus in a flash his entire family was wiped out plunging his countless admirers into eternal doom.
There is a lesson for everybody in his tragedy that, one should not panic when emergency strikes. Panic paralyses the reasoning and leads to irrational actions.
Now think what possible actions GV Atri could have taken in those terrible moments
  • He could have yelled for help
  • He could have left his son on one side and tried to throw something like a rope, a twig, rod whatever was available on the river bed at them
  • He could have shouted at them to remain calm, try to keep afloat
  • He could have warned them not to hold each others hands
  • He could have removed his lungi, make it in the form of a rope and threw it at them
  • If nothing could be done he could at least remain on the bank for his son.
How many options you have in an emergency situation?
  • To run away from the scene of an accident
  • To ask others to do the first aid
  • To do it yourself
This book is not for persons who belong to the first category, partly to the second category and entirely for the third category (Fig. 1.3).6
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Fig. 1.3: When encountered with an emergency how many options do you have?
Why third option is the best?
Listen to the fabble of the Good Samaritan. Also imagine if you are faced with an emergency and the other person thinks the way you do! Have you not heard. “Do unto others what you would like others to do for you”?
The Parable of a Good Samaritan
This is a very famous parable told by Jesus Christ about a good human being. A trader was on his way back home when he was attacked by a group of robbers who robbed him of all his belongings and assaulted him. They left him profusely bleeding by the road side and decamped with all his valuables. After some time a person came by the way and saw the wounded trader and asked him what had happened. After learning about the incident, he sympathized with him, assured him all be well and cooly walked his way. Another person approached him after a few minutes and on learning about his plight, told him he will go the to the nearby village, find help and send it to him.
Late a third person came along, enquired with him, and on seeing his plight, decided to help him himself. He cleaned and nursed his wounds, bandaged them, lifted and put him on his horse and drove him to a nearby village. Then he got him medical help. Gave money to the doctors, intimated his relatives and left him after they came. Now Jesus asked the people who among the three was a good human being. The unanimous choice obviously was the third person.
So when you are faced with an emergency situation, you could adopt one of the following three routes.
  • Be an onlooker
  • Try to tell somebody to help him
  • Help the victim yourself.
Remember when you adopt the third route you are being a good human being. It is imperative you be that way so that in the event you are at the receiving end imagine the repercussions if others try not to help you but leave it to your fate. You certainly do not want them to do that for you. Then you don't do it for others in an emergency. Remember the famous advise by Jesus,” Do Unto others, what you want them to do for you!” This is the right philosophy in life.
Do you know how Orthopaedic emergencies began? (Fig. 1.4)
  • It all began with the evolution of mankind
  • There are two theories of evolution let us explore both
  • According to the first, God created human beings
  • He made a man (Adam) from mud (Dost thou are, to dust thou returnest)
  • He decided to create a company for man8
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    Fig. 1.4: Do you know how orthopaedic emergencies began?
  • Plucked out a rib from the man he created (Hence I believe God is the first Orthopaedic Surgeon) and made a woman (Eve).
Evolution of Mankind
  • Thus the very first Orthopaedic surgery done by God was to create a woman.
  • He told the couple you are my replica (Hence God is within us, but still, We look for God everywhere)
  • He told them the entire heaven is yours
  • But don't eat the forbidden apple
  • This made them curious (Bane of human beings)
  • Satan came in the form of a snake and told them to eat the apple and you will become God (Temptation)
  • They ate (First Sin) presuming God will not know.
The First Sin and Orthopaedic Emergency
  • Nobody can fool God, he instantly knew and banished them to earth
  • Thus man lost the heaven which he had got so easily and now he is on a constant look out for heaven on earth and instead is creating hell on earth in search of it through his greed, temptation and sin and thus has created miseries
  • Orthopaedic emergencies are part of these miseries created by man himself
  • We search for God, worships all sorts of God when God is within us
  • Instead of being second to God, we try to play God ourselves and see what we have created
Oh, for the purists the origin of mankind is an evolution!
  • Man evolved from monkeys so says purist
  • Became a biped from a quadruped (Fig. 1.5)
  • The beginning of all Orthopaedic emergencies is because of this two legged stance.
  • Have you ever heard animal facing an Orthopaedic emergency? No it is only man who creates and lands himself in all sorts of Orthopaedic emergencies.
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Fig. 1.5: The evolution of man
Do You Agree with Me that We Create Orthopaedic Emergencies
  • Nearly 90% emergencies are man made and are due to road accidents, falls, assault etc. (Fig. 1.6)
  • Only 10% are beyond our control
  • Most of the emergencies are due to Man's vices like haste, greed, competition, discourtesy, rebellions, dishonesty to name a few
  • Orthopaedic emergencies are waiting to happen in these 24 hours anytime, anywhere and to anybody. No person on this earth is immune.
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Fig. 1.6: Orthopaedic emergencies are man made
When faced with a Goliath (Emergency) become a David (First Aid)
  • If you are in a situation with an Orthopaedic emergency staring at your face, how are you going to tackle it? (Fig. 1.7).
  • My endeavor is to make you fit enough to face the devil
  • If you are at the scene of an Orthopaedic emergency act soon till medical help reaches you or you reach the victim to a hospital.
The David Goliath Story
Goliath was a huge devil who terrorized people. He vanquished everybody who came to fight him. With nobody to confront him he bragged and challenged the villagers to fight him. When none came forward, David a young shepherd with a small frame accepted his challenge and came forward to fight him.
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Fig. 1.7: How to tackle an orthopaedic emergency?
Seeing David, Goliath broke into a big guffaw. Villagers stepped back in fear fearing the worst for David. But David was calm and composed. He knew exactly how he was going to fight his big enemy. He chose a small pebble, tied it in a cloth, whirled it ferociously and released the pebble aiming at Goliath's temple. Before he could realize David's plan, the pebble had stuck Goliath's temple and he lay dead within seconds. David had thus achieved the impossible. He slained the mighty Goliath with a small pebble. It was David's commonsense that floored the Goliath. Hence a little common sense is enough to tackle a Goliath, an Emergency, in life. But remember common sense is not common.
  • Life threatening (Most of these are non-orthopedic)
  • Life disturbing or disabling (Most of these are orthopedic)
In either situations, First Aid is the tool to tackle an emergency.
What is First Aid?
It is the aid given to a victim in the scene of an emergency
Goals of first aid (3P's):
  • Preserve life
  • Prevent further damage
  • Promote recovery.
Medical Aid
It is the treatment given by trained medical professionals (Fig. 1.8).13
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Fig. 1.8: Medical aid is the treatment given by medical professionals
  • Injury to vital organs like brain, heart, kidney, spleen, etc
  • Bleeding
  • Shock due to high anxiety (Neurogenic shock) or due to blood loss (Hypovolemic shock)
  • Multiple fractures
  • Compound fractures
  • Pelvic fractures
  • Spine fractures
However this is outside the scope of this book.
Life Disturbing or Disabling Emergencies in Orthopaedics
  • Sprains
  • Strains
  • Subluxations
  • Muscle spasms
  • Fractures
  • Dislocations
These are common and certainly frustrate the victim no end. Most of the orthopedic emergencies fall in this group.
  • Sometimes orthopedic emergencies could be associated with life threatening problems
  • Hence, learn life saving skills before you learn bone mending skills. Remember life saved is a life gained.
  • If patient survives, any problem can be tackled but reverse is not true.
  • Lots of importance should be placed on saving the life of a victim and to do this remember the A to F Concept.
  • To save a life one has to be trained in CPR (Cardio- Pulmonary Resuscitation) techniques.
  • Remember what Jesus said, what is the use if you win the whole world and lose your own soul and thus what is the use if you mend all the 206 bones and lose an all important life.
Thus the Mantra in managing an Orthopaedic Emergency is save the endangered life first before you mend a bone.
First aid (You want to be on which side of the fence?)
You now know the definition of a first aid, now what kind of first aider you want to be, good or bad? What are the characters associated with either? (Fig. 1.9).15
Good first aider
Bad First Aider
A – Alacrity
A – Apathy
I – Intelligence
I – Indecision
D – Decisions
–He aids the victim to recovery.
–Here the first aid will become the best aid.
D – Delay
–He aids the victim to mortuary
–Here the first aid will invariably become the last aid!
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Fig. 1.9: Bad first aid may indeed be the last aid!
Qualities Desired For A Good First Aider (5C's)
  • Common sense (Fig. 1.10)
  • Calm mind
  • Courage
  • Compassion
  • Chivalry
Just as water douses fire, A cool mind douses panic, fear and anxiety.
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Fig. 1.10: Remember common sense is not common
When to institute measures to tackle an Orthopaedic emergency
  • When life is not affected or
  • When affected life is made safe by you by practicing various life saving measures (By practicing Golden Hour principle)
Let us hence first learn everything about the all important life saving measures before we learn how to manage an Orthopaedic emergency.
Do you know the alphabets in emergencies?
Examine an victim in the following order in an emergency situation:
  • A– Airway: Needs to be free from all obstructions
  • B– Breathing: Very important as brain cannot tolerate lack of oxygen for more than 3 minutes
  • C– Circulation: Loss of blood could prove fatal
  • D– Digestive System: Damage to liver, intestines, spleen etc. Could snuff out life if ignored
  • E– Excretory System: injuries to kidney, bladder etc are dangerous
  • F– Fractures: these are not emergencies barring a few, and usually will not kill a victim
  • G– Go To The First Again: After the ‘primary survey’, go back and begin again for a secondary survey' and inititate the treatment.
Note: It is imperative to follow this protocol in emergencies. Do not rush to treat fractures ignoring these A to E management! Now let us try to know the management beginning from ‘A’.
  • Primary survey: Quick initial examination of an injured
  • Secondary survery: Slow detailed second examination of an injured.
A–AIRWAY (Do not force through a blocked traffic)
  • Clean the mouth of debris (tongue fall, blood, dentures, broken tooth, saliva, vomitus etc) (Fig. 1.11A.)
  • Remove the tongue fall if any by swiping your fingers
  • Remove the dentures if any
  • Now extend the neck, this opens the blocked airway (Fig. 1.11B).
Now institute Cardio-Pulmonary Resuscitation (CPR) measures if the breathing and heart beats have stopped.
Remember: A clear airway is required for air to flow in and out of the body. Hence do everything possible to ensure a free airway.
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Fig. 1.11A: Clear the mouth of debris
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Fig. 1.11B: Extend the neck
The Kiss of Life-Nothing Obscene, It Is A Godly Act
Once the airway is clear and if the patient is not breathing commence, mouth to mouth respiration as follows:
  • Cover the mouth with a clean hanky and pinch the nose (Fig 1.12A)
  • Blow into the victims mouth and see for the chest rise (Fig. 1.12B)
  • If mouth is injured, try nose to mouth respiration
  • Check the breathing now
Note: Rate of Breathing– 16–20 times/minute, so give artificial respiration at this rate.
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Fig. 1.12A: Pinch the nose
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Fig. 1.12B: Blow into the victim's mouth
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Fig. 1.13: Mouth to nose respiration
Mouth To Nose Respiration
  • Sometimes mouth to mouth respiration is not possible because of mouth injuries
  • In such a case institute a mouth to nose respiration, closing the mouth shut (Fig. 1.13)
    What will you do if both mouth to mouth and mouth to nose respiration is not possible? Then you may have to make an opening in the wind pipe with a sharp object just below the adam's apple (This is called tracheotomy).
  • Watch the chest fall, blow again and keep doing it till the victim starts breathing again (Fig. 1.14A).
In A Baby Things Are Different
  • In a baby, cover the mouth and nose of the infant, pull in making the chest rise (Fig. 1.14B).
  • Remove your mouth and see the chest fall
  • Do it at a faster rate than you do for adults as the breathing rate is 30–40 times/mt in a child
  • Be gentle with kids.
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Fig. 1.14A: Checking for restarting of breathing
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Fig. 1.14B: Artificial respiration in an infant
C– Circulation (Beware, chest compression can be dangerous)
  • If the heart stops, circulation to the brain ceases
  • Mouth to mouth respiration only will then be useless
  • Feel the radial pulse or carotid pulse (Fig. 1.15A)
  • Try direct heart auscultation
  • Stop the bleeding if any
  • Institute external cardiac massage if the heart has stopped (Fig. 1.15B).
  • Ensue patient is on a firm surface before commecing Cardiac massage.
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Fig. 1.15A: Feel for the carotid artery
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Fig. 1.15B: External cardiac massage
CPR Technique
Chest Compression Technique (Strictly needs training)
  • Has to be done by those trained in CPRT
  • Place the bottom of the heel about three to four finger widths up from the bottom of the breastbone (Fig. 1.15B)22
  • Keep the fingers and the thumb raised
  • Put pressure on this hand with your other hand (Fig. 1.16A)
  • Press down for 1½ inches (Fig. 1.16B)
  • Give 15 compressions every 15 seconds (about 60/mt)
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    Fig. 1.16A: Putting pressure with both hands
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    Fig. 1.16B: Press down firmly
  • Follow this with 2 mouth to mouth respiration
  • Check the carotid pulse after 1 minute and then every 3 minute.
Cardiac Compression in Children—Be gentle
  • In children press with a single hand slightly at a faster rate (Fig. 1.17A)
  • In infants turn it upside down and use only two fingers (Figs 1.17B and C).
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Fig. 1.17A: Cardiac massage in children
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Fig. 1.17B: Turn the infant upside down
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Fig. 1.17C: Press with only two fingers
Stop The Bloody Bleeding
  • Remember your body has just 5–6 litres of blood
  • Blood is precious hence stop its leak immediately
  • Lay the victim down, remove the clothing around the wound
  • Press hard on the wound either with your bare hand or with a clean cloth and hold it for 5–15 minutes (Fig. 1.18A).
Measures to stop bleeding (But Do not forget Sudha Chandran)
  • Elevation–raise the wounded area above the heart level (Fig. 1.18B)
  • Direct Compression (Fig. 1.18C)
  • Pressure bandage if the blood continue to leak inspite of the compression25
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    Fig. 1.18A: Pressing directly over the wound
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    Fig. 1.18B: Elevation of the limb
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    Fig. 1.18C: Applying pressure bandage
  • Squeezing the sides of the wound if a foreign body like a sharp glasspiece is embedded within the wound (Fig. 1.19).
  • Pressing on a pressure point of the blood vessels in the arm or leg (Figs 1.20A and B)
  • Tourniquet–Only as a last resort
The Tragic Tale of Sudha Chandran
Sudha Chandran is a danseuse, a cine and TV Actress of repute. She is known for her exemplary feat of dancing, that too bharatnatayam, without one of her legs! She had started giving stage performances when she was barely in her teens. While returning home after one of her programs her bus met with a tragic accident in the midnight on a ghat section. She sustained crush injury of her right leg and was taken to a nearby hospital for treatment.27
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Fig. 1.19: Squeezing either side of a wound with a foreign body
There a doctor applied a tight tourniquet around her thigh to stop the bleeding. He forgot to inform about it to her or her other co-passengers nor mentioned it in her OPD slip. She was referred to a major hospital to a nearby city for further treatment with the tourniquet on. She could manage to reach the city only the next day morning after more than 6–8 hours.
The doctors in the city hospital to their horror noticed that her tourniquet tied leg had become gangrenous. They had to do a below knee amputation to save her life. All this happened because of the improper application and lack of knowledge of the procedures to be followed during the application of a tourniquet. Hence beware and be wary 28of the tourniquets regarding its utility in the management of bleeding wounds! It can spell doom to the vascularity of the limb and lead to disastrous complications. And everybody is not a Sudha Chandran who can turn a tragedy into a superhuman feat!
Pressure Points Could Come In Handy In Difficult Situations
  • If bleeding is severe from the arm or leg
  • If direct pressure cannot be applied over the bleeding wound
  • While a dressing is being prepared
  • In these situations bleeding can be stopped by blocking the blood vessel against some bone points
  • Do not press for more than 15 minutes
  • Two important pressure points are, pressing against the brachial artery (Upper arm) (Fig. 1.20A) and femoral artery (Leg) (Fig. 1.20B).
How to stop bleeding if something is embedded?
  • If an object, like a glass piece, is embedded within a wound, do not attempt to remove it as it may cause more bleeding due to damage to muscles, blood vessels underneath
  • Squeeze the edges of the wound together for 5–15 minutes. Do not try to remove the object (Fig. 1.21A)
  • Put a circular cotton pad over the wound (Fig. 1.21B)
  • Bandage diagonally without putting pressure on the protruding object (Fig. 1.21C)
  • Shift the patient to the hospital at the earliest
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Fig. 1.20A: Pressing against the brachial artery
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Fig. 1.20B: Pressing against the femoral artery
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Fig. 1.21A: Squeeze the edges of the wound
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Fig. 1.21B: Cover the wound with a pad
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Fig. 1.21C: Put a pressureless bandage
D–Digestive System (An Abdominal injury could be catastrophic–Beware)
  • Blunt injury abdomen is a very dangerous situation
  • It is due to car accident, fall, stab wound, assault etc.
  • Abdomen has many vital organs that could be injured
  • Pain and tenderness
  • Bruises and abrasions
  • Nausea and vomiting
  • Board like rigidity of the abdomen (This is the characteristic feature and is diagnostic)
  • Guarding
  • Patient may rapidly lose blood internally
  • Signs of rapidly progressing shock
  • It is a grave emergency, act very fast.
An Abdominal Injury Could Prove Fatal-Act Fast
Measures to Close a Wound if present
  • If the wound is running lengthways, lay the casualty flat on the back, with the feet slightly raised (Fig. 1.22A)
  • If the wound runs across the abdomen, lay the casualty on his back with folded cloth beneath neck and shoulders (Fig. 1.22B)
  • Bend and support the knee with a cloth.
  • After making the patient comfortable, proceed to bandage the abdominal injury.
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Fig. 1.22A: Lay the injured flat on the back
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Fig. 1.22B: Support for the neck and knees
Do You Know What Amitabh Bacchan Has Got To Do With Abdominal Injury?
Amitabh a legendary icon of Bollywood was nearly done to death by a fatalistic abdominal injury. In Bangalore in 1983, during the shooting of the movie Coolie, a fight scene with Puneet Issar turned out to be nightmarish. He suffered a blunt injury of the abdomen due to a fall on the flat surface of a table. As a consequence he suffered large intestinal perforation and developed a fatal complication called faecal peritonitis.
He was shifted to St Philomena's Hospital immediately where an emergency laparotomy was performed and the rent in the intestine was closed and peritoneal lavage was given. His condition deteriorated and he was shifted to Mumbai's Breach Candy Hospital where he was operated again. After battling for days he slowly recovered while the entire nation prayed for his well being. The recent abdominal problem he faced in November 2005 was also a complication of the same earlier problem. Amitabh suffered a near fatal blunt injury of the abdomen got prompt medical attention and thus survived. But how many are that lucky.
What to do if somebody gets blunt injury abdomen on a road and medical services are not easily available, in these situations promptness is the key. Act fast or it maybe to late.
Bandaging Techniques
  • Gently remove the clothing (Fig. 1.23A)
  • Cover the wound with a clean cloth (Fig. 1.23B)
  • Cover the dressing with a firm bandage but do not press on the wound and the knot should be away (Fig. 1.23C)
  • Keep the victim warm by covering with a blanket (Fig. 1.23D)
  • Periodically check the pulse
  • Shift the victim quickly to a hospital
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A: —Remove the clothing
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B: —Cover the wound with a clean cloth
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C: —Apply a firm bandage
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D: —Cover the patient with a blanket
Figs 1.23A to D: Measures to manage an abdominal injury
Here the following organs could be injured:
  • Injury to the kidneys
  • Injury to the bladder as in pelvic injuries
  • Injury to the urethra
  • Injury to the genital organs
These are more common in pelvic injuries and in run over accidents.
Bone injuries could present as follows:
  • Simple fracture
  • Open or compound fractures
  • Multiple fractures
  • Fractures with joint injuries
  • Joint dislocations and subluxations
  • Fractures with multiple system injuries.
In the ABC's of emergency management remember fractures come last.
Remember Dr John's criteria
The best way to manage a fracture is to follow the 3's Principles (Splint, Sling, Strap) and for Spine injuries just SUPPORT.
Remember Head is on Top of All Your 206 Bones, Tackle It First (Fig. 1.24A)
  • If there is head injury with fracture then you need to tackle head injury first.37
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    Fig. 1.24A: Head injuries needs to be managed first
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    Fig. 1.24B: Apply a clean cloth and knot it at the back
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    Fig. 1.24C: Apply a knot in front
  • It is very common
  • There could be scalp injury, skull fractures and even internal brain damage
  • Scalp injuries bleed heavily
  • Cannot be taken lightly
  • There could be no apparent signs visible indicating head injury
  • Patient could be unconscious or highly irritable
Note: No head injury is simple so as to be taken lightly or so serious so as to despair! If a patient with head injury lies still don't presume everything is fine. It could be a lull before a storm! On the other hand if a patient is violent don't despair again because it could be just a sign of recovery after the storm! A still lying patient is an ominous 39sign, it could represent a serious head injury while a violent patient could mean just a brain irritability. So don't take both situations lightly.
Head Injury is An Enigma
First aid management of an head injury
  • Feel for the fracture first
  • If there is none, press a clean pad on it and hold
  • If you suspect a fracture place a ring pad
  • Secure the dressing with a triangular bandage
  • Ensure that the dressing will not slip by tying knots on the front and back (1.24B and C)
  • Fasten the bandage with a safety pin (Fig. 1.25A and B)
  • Shift the victim to a hospital
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Figs 1.25A and B: Technique of fixing the head bandage with a safety pin
Face injury
  • Cover the wound with a clean cloth and apply firm pressure (Fig. 1.26A)
  • Faster it with adhesive plaster (Fig. 1.26B)
Jaw injury
  • Support the broken jaw with the hand and place a cloth beneath (Fig. 1.26C)
  • Now wind another cloth, tie it across the face as shown in figures (Figs 1.26C and D).
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Figs 1.26A and B: Method of managing a face injury
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Figs 1.26C and D: Method of managing a jaw injury
  • Car accident most common cause for chest injuries
  • Sucking wound happens when the chest wall is perforated
Features of chest injury
  • Pain that increases with breathing and coughing
  • Difficulty in breathing
  • Blueness
First Aid
Seal the wound and put a sling (Fig. 1.27A to C)
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A: —Cover the chest injury with a clean cloth
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B: —Fix it with adhesive plasters
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C: —Tie a sling
Figs 1.27A to C: Method of managing a chest injury
Managing Complicated Rib Fractures
  • If a fractured rib damages the pleura, lungs, heart etc it is called complicated
  • This causes internal bleeding and is dangerous
  • Pain, shallow breathing, a feeling of tightness, bleeding etc. are the clinical features
  • Treat as mentioned earlier and put an elevation sling (Fig. 28A and B).
  • Elevate the injured limb to the level of the opposite shoulder and tie it with a sling.
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Figs 1.28A and B: Method of managing a complicated rib fracture
Do not Ignore Spine Injuries (Christoper Reeve the Superman was Reduced to a Super Vegetable!) (Fig. 1.29)
  • Neck and spine injuries are dangerous
  • A still Neck should instill fear in the minds of a first aider that there could be serious neck injury.
  • A frozen back, a painful back is waiting to tell a gory story of grievous injures to the spine
  • Ignore it at patients peril.
First aid
Neck injury: Support the neck on either side. Do not move the neck violently.
Back injury: Keep the patient still. Do not move the victim unnecessarily.47
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Fig. 1.29: Christopher Reeve a victim of neck injury
In either situations call for an ambulance or prepare a make shift stretcher if the medical help is far away. Shift the patient to a nearby hospital at the earliest.
Reel Superman was Indeed a Real Superman
Christopher Reeve shot into limelight as a flying superman. All his movies were mega hits and were loved by one and all from children to elders. During the shooting of one of the sequel he accidentally fell during a horse ride action stunt. Unfortunately his foot got stuck in the stirrup and he suffered a serious neck injury that left him paralyzed down the neck and became quadriplegic.
He fought valiantly against his injury for years and showed remarkable gut and gumption in overcoming his 48problem. His wife stood by him steadfastly. This act of his made him more popular than his movies. After years of struggle he succumbed to his injuries recently. After his death his wife too lost her battle against cancer and followed suit. So these were the real super couples who become immortal due to their grittiness against travesties of life.
So when you encounter a neck injury beware. It could prove fatal, near fatal or could lead to a morbidity life like Reeves that could put even death to shame!
After executing first aid to an injured victim the next important job is to shift the patient to a nearby hospital for medical aid.
Shift a Victim in the following situations
  • If there is immediate danger
  • If the victim have to be taken to a nearby hospital
  • To move the victim off a busy road
  • To move from the site of building collapse, from a staircase, trapped in a vehicle etc.
  • Stand close to the victim, ask him to put his arm around your shoulder, grip the clothing at the hip by putting your arm around the waist (Fig. 1.30)
  • Take the weight with your body and move forwards with short step.
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Fig. 1.30: Method of shifting a conscious injured victim
Shifting an Unconscious victim (If heavy and has to go a long distance)
  • It is very challenging to shift a heavy unconscious victim
  • Tie both the wrists of the victim with a belt, scarf, or bandage (Fig. 1.31A and B)
  • Kneel over the victim
  • Put the victim tied wrist across your neck (Fig. 1.31C)
  • Crouch and push forward slowly
  • Take the weight over your arms
  • Keep the victims head off the ground
Chair Shifting of a Conscious Person
  • Check the chair selected is strong
  • Seat the casualty well back in it facing forwards (Fig. 1.32A)
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A: —Kneel by the side of the victim
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B: —Tie both the wrists with a cloth
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C: —With the victim's tied hands across your neck, crouch and push forward slowly
Figs 1.31A to C: Method of shifting an unconscious person
  • Hold the chair from front and another helper from behind
  • Tilt the chair
  • You go down the stairs with the bearer at the front backing down (Fig. 1.32B)
Shifting A Light Victim
  • Grip the victim under the shoulder
  • Work your way backwards
  • Allow the victim's head to rest on your arms (Fig. 1.33)
  • If you have to go a long distance, or down the slope or staircase, crouch, support the victims head on your thigh, lock your wrists and pull.
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A: —Make the victim sit back in the chair
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Figs 1.32A and B: Method of chair shifting a conscious victim
—Tilt the chair while going down
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Fig. 1.33: Method of shifting a light victim
Improvising And Making A Make Shift Stretcher
This is necessary to make a on the spot stretcher for shifting an injured victim.
  • Take 2–3 coats or jackets and turn them inside out
  • Pass two strong poles through the sleeves (Fig. 1.34A)
  • Zip button the jackets (Fig. 1.34B)
  • Test with an uninjured victim first
  • Roll the casualty on the uninjured side (Fig. 1.34C)
  • Push the stretcher beneath the back.
  • Gently roll back the victim, lower it and then lift.
How to recognise an heart attack?
  • Severe crushing pain in the chest
  • Radiation to the arm, forearm and fingers
  • Breathlessness
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A: —Pass two poles through the coat sleves
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B: —Zip button the coats
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C: —Turn the victim to the uninjured side
Figs 1.34A to C: Method of improvising a stretcher
  • Profuse sweating
  • Giddiness
  • Unconsciousness
  • Previous history of chest pain
  • May be a Known diabetic or Hypertensive
What To Do, Whatever You Do, Act Fast
  • Identify the symptoms quickly as you have minutes left
  • If the victim is conscious, put him in a half sitting position, with head and shoulders supported and knees bent (Fig. 1.35)
  • Loosen the patients clothing around the neck, chest and waist to enable him to breathe
  • Do not give him any thing to eat or drink
  • Do not allow him to move around unnecessarily56
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    Fig. 1.35: Giving first aid to a heart attack victim
  • If unconscious, put him into the recovery position
  • Try and call his doctor.
  • If an unconscious victim is allowed to be in the face up position he is in the danger of choking with blood, vomit, saliva, dentures, broken tooth or the tongue fall back
  • The protective cough reflex is absent in these cases and they may fatally choke
  • Listen to the sound of breathing and see for the chest rise (Fig. 1.36A)
  • Clear the mouth of debris and begin CPR (Fig. 1.36B).
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Fig. 1.36A: Listen to the breath sounds and see for the chest rise
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Fig. 1.36B: Clear the mouth of the debris
A Victim Who Does Not Speak is Totally At Your Mercy
  • Kneel about hand span away
  • Turn the head towards you
  • Tuck the near arm under the body
  • Put the other arm across the chest
  • Put the far ankle over the near ankle (Fig. 1.37A)
  • Grip the clothing at the hip and turn (Fig. 1.37B)
  • Cushion the head and Support the body with your knee as he turns.
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Fig. 1.37A: Preparing to turn an unconscious victims
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Fig. 1.37B: Turn holding the clothing at the hip
Wait, Your Job Is Not Over Yet
  • Tilt the chin backwards to clear the throat (Fig. 1.38A)
  • This will keep the airway open and will prevent the tongue from slipping back (Fig. 1.38B)
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    Fig. 1.38A: Tilt the chin upwards to backwards
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    Fig. 1.38B: This position help to keep the airway open
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    Fig. 1.39A: Propping up the body and loosening tight clothing
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    Fig. 1.39B: Check for other injuries and stop bleeding
  • Bend the arm and leg nearest to your body to prop the body
  • Pull the other arm out or prevent her from rolling over onto her back.
Do You Know You Have Just Done A Very Noble Act!
  • Once the victim is in the recovery position, loosen any tight clothing at the neck, chest and waist to assist breathing (Fig. 1.39A)
  • Provide fresh air
  • Check for other injuries and stop bleeding (Fig. 1.39B)
  • Check the pockets for any piece of paper, identity card, medical card etc.
  • Call the hospital or police.
By all these measures enumerated so far you have now made the victim's life safe. It is now time to manage orthopedic emergencies.