Dr. Anand Deo
MBBS, Kathmandu University
Accidents are common. They can happen anywhere, anytime. Trauma is study of medical problems associated with physical injury. Injury is the adverse effect of physical force upon a person. Trauma is the commonest cause of death and disability in first 40years of life and the third commonest cause of death overall. We ourselves are part of accident or we may happen to witness one. Times like these are demanding, emergency help is needed. Medical personnel are not always available. A common person too can sometimes be of help if he/she knows what to look for and what to do. A little intervention can be lifesaving; can prolong the interval between life and death.
About 50% of deaths happen immediately after accident and it is usually impossible to save this fraction. Another 30% of deaths occur within hours of accident. This time frame of few hours is considered to be golden hour for, adequate measures if taken can save a great deal of life. Rest 20% deaths are due to lack of proper heath facilities and tend to occur over course of days. Chain of survival includes witnessing the event, call for help, resuscitation and early basic life support, advanced life support and finally the definitive treatment. Basic Life Support includes the measures to stabilize the victim’s condition, to prevent further deterioration. The aim is to maintain a low level of circulation until more definitive treatment with advanced life support can be given. The maneuvers are simple, can be performed by a common individual with little knowledge and training on the matter and yet lifesaving in many instances.
Consider a scenario, you see a bus accident and find people helplessly lying thereabout. Our moral asks us to help them in ways we could and we could do it better if we all know some basic steps.
Make sure you, the victim and the bystanders are safe; that there is no any element of further danger.
Go near the victim. Talk to him loud enough to hear. Ask him “What is your name?” “Are you alright?” “Open your eyes if you can hear me.” If the person can speak properly, follows your command without undue difficulty or noisy breathing, he is probably not near to any immediate grave danger. Leave him in this very position he is, provided there is no danger further. Try to find out what is wrong with him; get necessary help and reassess him regularly. If person can’t speak, shake his body gently and look for response. Shaking at shoulders or rubbing the victim’s chest with knuckles of your fingers is considered optimal.
Shout for help. Call at local health post or send someone if available to fetch some medical help. The basic life support (BLS) includes:
4. Airway (the passage through which air enters into lungs and leaves out from lungs),
5. Breathing (the act of exchange of gases between lungs and atmosphere), and
6. Circulation (flow of blood in body); Commonly abbreviated as ‘ABC’. Cervical spine (bone in Neck) has been given utmost importance as injury and destabilization of this area can cause serious damage to nerves around it leading to Quadra paresis (weakness of all hands and legs) and many other dangerous consequences including death. Ask victim if he feels pain anywhere in the body. If you suspect injury to head or neck, stabilize the neck of victim before anything else and maintain position while doing anything further.
Initial assessment: The initial assessment includes- LOOK, HEAR and FEEL: AIRWAY LOOK
For signs of airway obstruction: –
Flaring of alaenasi (lower part of side walls of nose).
– Use of accessory muscles for respiration (muscles of neck become more prominent; notch inlower middle of neck becomes more prominent when breathing strenuously).
– Gasping for air. – Look for any food material stuck or any liquid, saliva, blood, pooled in mouth, nose. – Unconsciousness or declining consciousness.
Is there any noisy breathing, gurgling or stridor? Can victim speak properly, can he complete sentences?
FEEL Feel for the presence of air movement at tip of victim’s nose or mouth (if open) with the back of your hand or skin of your cheek.
If the chest wall on both halves of midline and abdominal wall are moving periodically or not? How many times chest and abdominal wall moves up and down in a minute? Are both halves moving equally or not? The depth of respiration.
Place ear near the nose of victim to hear for air flow. Place ear near to victim’s chest in side walls for any noise while breathing. Ask victim to talk and hear if he can complete sentences.
Feel for excessive perspiration. Run your finger down the middle of neck and feel for any tracheal deviation (normally trachea, the windpipe can be felt as cartilaginous structure running straightly in midline of neck).
Touch both halves of chest wall and feel for movements of chest, if they are equal on both sides.
For the level of consciousness of victim: if victim can follow vocal commands or responds only to painful stimulus or unresponsive at all. Color of skin: Pale, red or blue. Look in palm, tongue, lips, and earlobes. Look for any site of external bleeding.
Place ear on left side of chest and try to hear heart sounds. Ask victim if he is having headache, feeling dizzy
Check for pulse at just above wrist for rate, quality, and regularity. Feel victim’s palms and soles, finger if they’re cold or warm enough.
After initial assessment:
Make airway patent:
If injury to neck is not suspected, place the victim in recovery position. Head is tilted back. Place the near arm right angle to body. Draw the furthest arm across the chest and the back of hand over the cheek. Keep this here whilst you raise the furthest leg by grasping at top of knee. Gently pull on the knee so as the victim pivots on to their side facing you. The victim should be fully over and stable.
Draw up the leg at 90 degrees over another. This position lets the secretion inside mouth flow outside with gravity without letting it pool in lower cheek. Now, turn the victim on his back. Clear anything present in mouth, nose, any food, blood, saliva. To do this you may need to insert one or two of your fingers inside victim’s mouth and swipe the mouth out.
Maintain the patency of airway:
Most common cause of blocked airway in case of trauma is falling back of tongue. This can be prevented by placing hand on victim’s forehead and tilting his neck backwards, lifting the chin up gently using fingers and by pulling up the lower jaw from both sides. Again, neck tilting should be avoided in victims with injury to cervical spine.
Cardio-Pulmonary Resuscitation (CPR):
Heart and lung functions are of paramount importance to sustain life and have to be preserved. CPR is to maintain blood circulation and ensure that blood is receiving adequate oxygen. The normal atmospheric air consists of 20% oxygen, and the air we breathe out contains about 16% of oxygen. The oxygen in air we breathe out is enough to deliver ample oxygen to victim if done properly.Check for pulse just above the wrist; its rate, rhythm, quality. CPR becomes more vital if heart beat is slowing down, pulse is slow and weak, hands and feet are cold to touch or body is pale. These signs indicate body is not receiving adequate blood. During CPR, heart is pressed between sternum (breast bone; the bone at center of chest in front) and vertebral column (back bone) so as to mechanically pump out enough blood in vessels and also to excite the heart to contract itself more forcefully. Place the victim flat with face up on a hard surface. Ground is hard enough. Interlock fingers of both hands and place it over midline at the level of nipple (corresponds almost to junction of middle and lower third of sternum beneath which heart lies). Lean over victim. Straighten your elbow and press from shoulders. Do not bend elbow while pressing. Press hard enough to depress chest to about 4-5 centimeters each time. Release the chest and allow it to recoil completely. Press hard and fast at rate of around 100-120/min. Two rescue breathes are to be provided after each 30 chest compressions. For rescue breath, close nostril, tilt neck backward, pull lower jaw up, open victim’s mouth, place your mouth against his in air-tight fashion and blow in air as much as you can in one second. Look at chest of victim as you blow air in to see if chest rises. Effective mouth to mouth breathing is indicated by rise in chest wall as you blow in air. Do this for 2 minutes and check for pulse again. Repeat once again for 2 minutes and check for pulse. Most victims need defibrillator if CPR does no good in 2-3 cycles. Seek definitive care.
Once the patient is stabilized and awaiting further medical help look for any external sites of bleeding and if present try to arrest bleeding by pressing over the site firmly with a clean piece of cloth. If the patient complains of pain in hands, legs, or when a fracture is suspected, try to stabilize the affected part. Any wooden plank or even umbrella, stick, newspaper roll can be used to support the affected part in such a way that the part does not move considerably. You may clean any obvious external wound, cut injury with free flowing clean water so as to decrease the risk of contamination. Life is vital. May we save a few.