Benefits of doing this courses

This course will provide you with the knowledge and skills to assess and treat patients with minor injuries.

Your patients will receive a safe, high standard of care as you will be skilled and competent to assess and treat patients and know when to refer them on to further care.

On successful completion of the course you will be able to assess patients with a variety of presenting complaints and will be competent to treatment patients with minor injury conditions including joint examinations, neck, shoulder, elbow, wrist and hand, back and hip examination, knee, lower leg and ankle/foot.  Practical skills including wound closure, local anaesthetic and application of plaster of Paris casts.

To do this course in a classroom can take two week and cost in excess of £1200

What is a Minor Injury?

What constitutes a minor injury is open to debate however it can be defined as an injury that isn’t life threatening. This includes most injuries to the limbs with the notable exemption of a fractured femur or Pelvis which can be fatal due to the amount of blood that can be lost. Although not life threatening some minor injuries such as dislocations and other fracture can be very disabling if not recognised and treated correctly..

Assessment

 At the end of each category you will need to complete and submit a case study in order to progress to the next section, there are also a number of MCQ Quizzes which you will need to pass with a minimum score of 60% in order to achieve the final award.

Chest Wounds     

There are several different chest injuries.

Fractures of the chest wall have been previously covered.

Remaining injuries either effect;

• Lungs

• Diaphragm

• Trachea

• Heart

• Major Blood Vessels

• Oesophagus

Lungs

There are a number of lung injuries that can result from trauma;

Pulmonary contusion

Pulmonary contusion is bruising of the lungs causing bleeding into the Alveoli. This decreases gaseous exchange and lowers oxygen level in blood. Support patient with IV fluids (if shocked) and oxygen if available. Excessive fluid therapy may causes more complications,

Simple Pneumothorax

A simple Pneumothorax is caused by trauma or can happen spontaneously. Degree of compromise to breathing depends on size of Pneumothorax. Small tears will heal themselves, monitor in case it becomes a tension Pneumothorax and treat symptomatically.

Open Pneumothorax

An open Pneumothorax is known as a ‘sucking chest wound’ caused by penetrating trauma which will allow air to enter the chest cavity from outside.  Bubbling of blood in the wound may be seen on expiration. Air may be present in the surrounding tissue (Subcutaneous emphysema) which feels like “bubble wrap”.   

 If available use an Asherman chest seal or Bolin chest seal to cover the wound this will allow air out of the chest but prevent more from being sucked in. If there is more than one wound place occlusive dressings over the others.

 Tension Pneumothorax 

A Tension Pneumothorax occurs when air enters the pleura but cannot escape, as pressure builds up it collapses the lung on the affected side, as it progresses it can also affect the heart and other lung. Potential signs include; diminished or absent breath sound, unilateral chest movement, fast breathing, lowering blood pressure, distended neck veins and cyanosis. If you see the trachea has moved away from the midline towards the unaffected side this is a very serious problem. Support blood pressure and oxygenation. The definitive treatment is by needle decompression.

Locate point of entry between 2nd and 3rd ribs in a line traced down from the middle of the collar bone. This is known as 2nd intercostals space, midclavicular line.

Insert a needle (max length 3.25”) over the top border of the 3rd rib at 90 degrees into the chest. This position will keep it away from nerves and blood vessels that run along the bottom of ribs and avoid puncturing the heart.

You may feel a pop or hear a hiss of air as the needle releases the pressure. A good tip is to attach a syringe to the needle this will provide stability and you may see the plunger rise as air is released from the chest.

Once decompression has been achieved stabilise the needle in position and cover with a chest seal if available.

Haemothorax

A Haemothorax is bleeding into the chest cavity will present with both breathing and circulation problems. Which will both require support. A chest drain is the definitive treatment when surgery is not available.

 Kits are available with all the necessary equipment to perform the procedure.

There are several videos on “youtube” which demonstrate this procedure well.

 Clean the skin with antiseptic solution then inject 1% lignocaine analgesia into skin, muscle and pleura in the fifth or sixth intercostal space, in the midaxillary line.

Insert a needle with syringe attached into the chest at this point and pull back on plunger to remove blood to confirm haemothorax.

Make an incision just above the rib to avoid damaging the

vessels and nerves under the lower part of the rib.

The underlying tissues are parted by blunt dissection using curved artery forceps. If cut with a knife the tissues will take longer to heal.

Use the forceps to grasp the tube at its tip and place it into the chest.

Close the incision with sutures, using one stitch to anchor the tube then apply a dressing.

Connect the tube to the drainage system and mark the initial level of fluid in the drainage bottle. Keep a clamp handy to place on tube when changing bottles.

If the chest drain is working correctly you will see bubbles and blood collecting in the bottle or bag. The patients respiratory state can be monitored by observing the movement of blood in the tube this is called swinging, the bigger the movement the deep the breath, the faster the movement the faster the rate of respirations.

Diaphragm

This is a sheet of muscle that stretches across the bottom of the chest and is an essential part of respiration. It can be damaged by blunt or penetrating trauma or by pressure changes during an explosion. If it tears, abdominal organs may become herniated through the tear which will interfere with respiration and may damage the organs. It requires surgery to repair.

Trachea

Damage to the trachea will affect breathing. Monitor respiration rate, oxygen saturation, movement of chest, listen for unequal or absent breath sounds. Give oxygen and suction airway, avoid intubation and positive ventilation with bag, valve and mask unless absolutely necessary as it may further damage the airway. Cover any open wounds, infection is a common problem so prophylactic antibiotics should be given.

Heart

Two conditions affect the heart during trauma;

Myocardial Contusions

Which is bruising of the heart muscle, this shows the same signs as a heart attack and can cause cardiogenic shock it should be treated in the same way with careful monitoring of patient vital signs particularly blood pressure and oxygen saturations. It presents as central chest pain following a history of chest trauma.

Cardiac Tamponade 

Which is bleeding inside the sac surrounding the heart. As the blood builds up it compresses the ventricles of the heart and rapidly affects the heart function. It presents with three symptoms known collectively as Becks triad; a low blood pressure, muffled heart sounds and distended neck veins. Patients are often also breathless and confused. IV fluids should be given to maintain a radial pulse.

There is a technique called Pericardiocentesis, which involves inserting a needle  with syringe though the chest wall into the pericardial sac and removing blood,  as little as 30-50ml may produce dramatic hemodynamic improvement. However doing so without x-ray equipment is extremely hazardous.

Major Blood Vessels

Vessels can be damaged by blunt or penetrating trauma, explosion or deceleration injuries. If the aorta is completely severed death is rapid, if it is damaged but not severed a third of casualties die in first 24 hours and half within 48 hours. Aortic dissection is characterised by sudden onset ripping chest pain. Pain is often said to go through to back or into neck or jaw. Blood pressure is often low. Although major damage requires surgery, smaller tears may be managed medically by reducing heart rate (60-80 bpm) and systolic blood pressure (100-120) with beta blockers.

Oesophagus

In traumatic injuries the Oesophagus can be damaged by penetrating trauma. The main problem with this is that it allows gastric content to enter the chest cavity which can lead to pneumonia and sepsis. Treatment should include;

• Oxygen

• Keep patient nil by mouth

• Insert Naso-gastric (NG) tube to remove stomach contents

• Give IV Fluids

• IV Antibiotics

• IV Anti-emetics & IV Analgesia

Small tears may heal themselves, larger ones require surgery and are rapidly fatal.

Pain relief for casualties with chest injury

Fractured ribs and other chest injuries are painful when the casualty breathes it moves the broken ribs increasing the pain.

The casualty is reluctant to take deep breaths and to cough. This results in retained secretions, poor oxygenation and carbon dioxide retention. Infection and respiratory failure may follow.

It is therefore important to provide adequate pain relief to casualties with chest injuries to encourage them to breathe deeply.

Using Entonox in casualties with chest injury

Entonox diffuses into air-filled spaces, causing increases in pressure and volume. In a casualty with a pneumothorax using Entonox increases the size of the air collection and may cause it to develop into a tension pneumothorax. If possible a chest drain must be in place before Entonox is used where a pneumothorax is suspected.

Abdominal Injuries

The abdomen contains many organs and is separated from the thoracic cavity by the diaphragm. If the injury occurs before inspiration then the diaphragm will be high in the chest, at around nipple level. If the chest is fully expanded then the diaphragm will be flattened. This has to be considered when evaluating injuries. Three types of structure exist in the abdomen;

• Solid Organs

• Hollow Organs

• Vascular Structures

Solid organs include the Liver, Kidney, Pancreas and Spleen these tend to be very vascular and damage causes serious bleeding. Hollow organs such as Intestines, Stomach, Bladder and Gallbladder these rupture when damaged causing their contents to spill into the abdomen, leading to severe infection. The third group of structures include the Aorta, Femoral Artery and Vena Cava, if these are damaged it usually causes life threatening bleeding. If the diaphragm ruptures then abdominal content will enter the thoracic cavity become herniated and interfere with breathing.

Damage to the abdomen may be caused by blunt, penetrating, shearing, deceleration and blast injuries.

There is limited austere treatment.

In blunt injuries treat pain, shock and if signs of infection develop give a broad spectrum antibiotic and hope.

In penetrating injuries close the wound, treat pain, shock and if signs of infection develop give a broad spectrum antibiotic and hope.

If the wound is open then the organs may protrude from the abdomen. These should be covered with damp dressings or sheets of cling film, do not allow them to dry out. If it is an austere situation the contents can be replaced and abdominal cavity irrigated with several litres of normal fluid before the wound is closed.