Wound Management and Trauma Care

• Traumatology involves diagnosing and treating severe or acute physical injuries
• The goal of caring for orthopedic trauma patients is to restore and preserve function

Socio-Economic and medical importance of injuries

• Injury is the leading cause of death in adults under 45 worldwide
• Injury represents a major cost to individuals, healthcare systems, and society
• Common causes of traumatic injury include road traffic accidents and falls
• Injuries from road traffic accidents tend to be more severe than those from falls, due to the high velocity of the trauma
• The World Health Organization (WHO) reported 1.25 million deaths from road traffic injuries in 2014
• Trauma is expected to rise to the 3rd leading cause of disability worldwide by 2030

Mechanism of injury

• Trauma happens from mechanical injuries with a degree of severity
• External force of energy impacts the body, inducing structural or physiological changes
• Traumatic injuries range from minor isolated wounds to complex injuries involving multiple organ systems

Trimodal distribution of Trauma deaths

• Deaths from trauma occur in a trimodal distribution
• The first peak includes victims who die before receiving medical attention
• The second peak occurs within a few hours after injury and is referred to as the golden hour
• The golden hour timeframe incorporates activation of the emergency medical system, stabilization in the prehospital setting, and transportation to a medical facility
• The golden hour also includes rapid resuscitation upon arrival in the emergency department and definitive care
• The third death peak occurs days to weeks after injury due to complications, including infection or multiple organ dysfunction syndrome(MODS)
• Location of death for first peak is at the scene or en route to a medical facility
• The cause of death during the first peak is laceration of the brain or brainstem, high spinal cord injury, injury to heart, aorta, or other large vessels
• The location of death for the second peak is the emergency department operating room
• The cause of death during the second peak is subdural or epidural hematoma, hemo-pneumothorax, ruptured spleen, liver laceration, pelvic fracture, and other injuries associated with extensive blood loss
• The location of death for the third peak is the critical care unit
• The cuase of death during the third peak is Sepsis, multiple organ dysfunction syndrome(MODS)

Polytrauma

• Polytrauma involves injury to multiple organ systems that cause a life-threatening condition
• Trauma patients require a systematic evaluation to avoid missing any injuries

Classification of common traumatic injuries

• Soft-tissue injuries include sprains, strains, and contusions
• Blunt trauma is a common form of injury that results from energy transfer causing tissue compression
• Gunshot and stab wounds are penetrating traumas
• Severity of penetrating injuries depends on the velocity of the penetrating force
• Stab wounds represent a low velocity
• Handguns are medium velocity
• Military rifles and shotguns represent high velocity
• Thermal injuries include burn injuries, chemical burns, and frostbite injury

Injury scoring system

• The purpose of injury scoring systems is to classify the severity of injury and predict patient outcome
• Examples of injury scoring systems include the Injury Severity Score (ISS), the Abbreviated Injury Score (AIS), and the Revised Trauma Score (RTS)

Initial Management of Trauma Patient

• Primary survey includes A, B, C, D, E approach
• Examine, diagnose, and treat life-threatening injuries during the primary survey
• The simplest treatment possible should be used to stabilize the patient's condition
• Resuscitation phase involves hypovolaemia and haemorrhage control
• Secondary survey includes a complete patient examination to ensure no other injuries are missed which includes lab tests, radiology, scans etc
• Definitive care phase involves transferring the patient to the operating theater, trauma center, ICU, or ward

ABCDE Approach

• A is Airway with cervical spine control
• B is Breathing and Ventilation
• C is Circulation and haemorrhage control with checking for bleeding, colour, warmth and cap refill
• D is Disability and Dysfunction with checking AVPU pupils and blood glucose levels (BGL)
• E is Exposure and Environmental control to inspect all posterior surfaces and keep the patient warm

Orthopedic Primary Assessment

• Subjective assessment factors are reported by the patient
• Objective assessment includes observable/measurable data
• Six P’s of assessment data includes Pain, Pallor, Paresthesia, Pulses, Paralysis and/or Pressure

Diagnostic investigations

• Some diagnostic tests are physical examinations, blood tests, X-rays, ultrasound scans called FAST (Focused Assessment with Sonography for Trauma), and CT scans

FAST focused assessment with sonography for trauma

• Four regions are assessed with the FAST exam
• Perihepatic is one region
• Perisplenic is one region
• Pelvic region
• Pericardial region

Types of traumatic wounds

• Abrasion is a wound created by scraping or wearing away the skin
• Puncture is a wound caused by a narrow object and results in a relatively small skin opening relative to the depth
• Laceration is a deep cut or tear in the skin
• Gunshot is a wound caused by a bullet with high transfer of energy and extensive damage to tissues
• Blast is a complex wound that may involve penetrating fragments, extensive tissue damage or loss, and massive contamination with dirt and debris
• Crush injuries are caused by blunt trauma and may include injury to skin, muscle, or bone
• Bite injury is an animal or human bite with very high risk of infection

Classification of traumatic wound

• Clean traumatic wounds are wounds of traumatic origin with no evidence of macroscopic contamination or signs of active infection
• Contaminated traumatic wounds are of traumatic origin macroscopically contaminated like dead tissues and foreign bodies that occurred in a contaminated environment such as animal bites or puncture wounds
• Wounds of traumatic origin are considered infected when there of signs of infection

Steps of primary wound care

• Wound care includes analgesia, cleaning the skin with antiseptic solution, irrigation of wounds with saline, providing local anaesthetic (lidocaine)
• Surgical debridement can be performed to remove all dead tissue and foreign matter, wound closure with sutures for wounds that are less than 6 hours old
• Other steps for wound care includes wound dressing and tetanus prophylaxis +/-

Tetanus

• Tetanus is caused by a neurotoxin produced by Clostridium tetani, an anaerobic spore forming bacterium
• Spores are widespread in the environment, including in soil
• Human infection is acquired when tetanus spores enter wounds through contaminated trauma

Tetanus prophylaxis

• Tetanus is generally controlled by a basic immunisation programme, however if acquired the disease can be fatal
• Tetanus immunoglobulin should be given for patients with high risk wounds and those who have never received primary immunisation
• Patients who have been vaccinated against tetanus previously, should be given a booster for clean wounds if the last dose was given over 10 years ago
• All other wounds require a booster if the last does was given over 5 years ago

Explore wound management principles, from surgical debridement and tetanus prevention to trauma assessment. Learn about contaminated wounds, neurological assessments, and the critical 'golden hour' in trauma care. Review appropriate tetanus booster guidelines and wound care strategies.