51.1 Caring for a severely injured patient

A severely injured patient can be a very gruesome sight—so don’t panic! There will be much to do, so call for a nurse, a medical assistant, or an anaesthetist to help you. Two people can often work on the same patient simultaneously. First, preserve the patient’s life, particularly by restoring his airway and restoring his blood volume. More injured patients lose their lives unnecessarily from respiratory obstruction than from any other cause. After you have done this, take the patient’s history from anyone who was present at the accident. Extend this by quickly questioning the patient himself. Later, you can take a more complete history and examine him more thoroughly.

Figure 51.1: AN ACCIDENT RECEPTION AREA. You may not be able to provide all these things, but try to provide most of them. The best place to take severely injured patient may be your intensive care unit. (1) Drip–stand, (2) central venous pressure set, (3) sluice bin, (4) mobile lamp, (5) a completely equipped anaesthetic machine (and a ventilator if you have one), (6) sphygmomanometer and stethoscope, (7) large plug for X-ray machine, (8) several power points, (9) tape measure, torch, and scissors, (10) oxygen cylinder and flow meter with rebreathing bag, (11) special bed or tipping trolley, (12) sucker, (13) blood warming bath, (14) admission books, (15) X–ray machine, (16) charts, (17) bin for clothes. You will also need an ophthalmoscope and an auriscope, a labelling pen, urine test strips, drip sets, intravenous fluids and cannulae, and a chest drain set (65.2).

You will have to act quickly; no two injuries are quite the same, so vary the usual sequence of history taking and examination. Train yourself to recognizse the urgent situations quickly while they are still treatable, especially rupture of a patient’s spleen or liver, or an extradural haematoma.

Many mistakes are caused by not examining a patient carefully. His peripheral injuries are unlikely to kill him even if you do miss them, but you can easily overlook serious central ones, especially injuries to his chest and abdomen. You will not miss bone sticking out of his trouser leg, but you can easily miss blood in his thoracic cavity or a slowly developing haemoperitoneum.

You will need enough space to work in and the right equipment. Figure 51-1 shows the ideal set-up. Try to have as much of this equipment as you can immediately available. You are unlikely to have a special accident treatment area, so the best place to take an injured patient may be the simple intensive care unit described in Section 19.1 of Primary Anaesthesia or the theatre.

There are no hard and fast rules as to what should be first aid at the scene of an accident and what is only possible in hospital. Many of the procedures which follow are practical in both situations. When a patient has arrived in hospital, don’t let him wait around. If he needs a laparotomy for an abdominal injury, he should be on the operating table within an hour of admission.

• TROLLEY, resuscitation, tiltable at the head and foot, with a radio–translucent surface, a device to hold cassettes underneath, holders for an oxygen cylinder and a drip attachment, also a wire basket for the patient’s clothes and his property. You will find this very useful. In spite of its detailed specifications, it is really quite simple.