Injury is an insult to the body with the resultant adverse effect. This can be brought up by physical insult, chemical/toxic injury or thermal injury. Usually the patient presents with symptoms upon arrival to the health facility which includes pain, bleeding, swelling or loss of function of the affected organ.
18.3.1 Soft Tissue injuries
Diagnostic criteria
- Pain only, traumatic swelling, bruises with intact skin, cuts, abrasions, puncture wounds or open wounds of varying size and severity
- Injury to internal organs must be recognized and referred, including subtle signs of organ damage, e.g.:
o blood in the urine – kidney or bladder damage
o shock – internal bleeding
o blood or serous drainage from the ear or nose – skull base fracture - An injury causing a sprain or strain may be initially overlooked. Exclude fractures by performing appropriate X-rays
Note
- Closed injuries and fractures of long bones may be serious and damage blood vessels
- Contamination with dirt and soil complicates the outcome of treatment
Emergency management
- Immobilize injured limb after reduction by POP cast or splint
- Monitor vital signs
- Monitor the arterial pulse and capillary refill below an injury on the limb with swelling.
Wound care
- Surgical debridement of the wound
- Suture or splint when needed
- Avoid primary suture if the wound is infected:
o Dirty or contaminated
o Crushed
o In need of debridement
o Projectile inflicted
o Caused by bites
Pharmacological Treatment
A: Paracetamol 15 mg/kg PO 6 hourly per 24 hours
AND
A: Diclofenac 75 mg IM 6hourly if can’t tolerate oral medication
AND
B: Cloxacillin 500mg IV 6 hourly for 7 days
A: Ceftriaxone 1gm IV 8 hourly
B: Metronidazole 500mg IV 8 hourly
AND
A: Tetanus prophylaxis: 0.5 mL Tetanus toxoid and 1 mL Tetanus immunoglobulin (Depending on the immunization protocol)
Table 18.4: Protocol in Provision of Tetanus Prophylaxis
| Patient Category | Non-tetanus prone | Tetanus prone |
| Immunized and booster within 5 years | Nil | Nil |
| Immunized and 5 to 10 years since booster | Nil | TT |
| Immunized and >10 years | TT | TT |
| Incomplete immunization or unknown | TT and TIG | TT and TIG |
TT = Tetanus toxoid; TIG = Tetanus Immunoglobulin
18.3.2 Sprains and Strains
It is a type of soft tissue injury where the muscle and tendons are affected. Exclude fracture by performing x-ray
Diagnostic Criteria
- History of trauma
- Pain, especially on movement
- unable to use the limb
- Tenderness on touch
- Limited movement
These may be caused by:
- Sport injuries
- Slips and twists
- Overuse of muscles
- Abnormal posture
Note: In children always bear non-accidental injuries (assault) in mind.
Emergency Treatment
- Immobilize with firm bandage and/or temporary splinting e.g. triangular sling, back slab etc
- Children over 12 years and adults:
A: Ibuprofen200–400 mg PO 8 hourly
AND
A: Paracetamol 15 mg/kg PO 6 hourly per 24 hours.
- Perform X-ray to rule out dislocations or sublaxations
Referral
- If Severe progressive pain. Do X-ray to exclude bone fractures or joint dislocation.
- Progressive swelling
- Extensive bruising
- Deformity
- Joint tenderness on bone
- No response to treatment
- Severe limitation of movement
18.3.3 Extremity Fractures
Fractures of long bones of upper and lower limbs are quite common. If not properly treated they often lead to long-term deformities. Osteomyelitis is always the complication of open fractures. Hemorrhagic shock may occur in situations involving multiple fractures or pelvic ring fractures.
Diagnostic Criteria
- Pain, swelling
- Loss of limb function
- Deformity and abnormal movement
Investigation
- X-ray
Non–Pharmacological Treatment
Community / dispensary level
- Immobilize injured limb by POP cast or splint.
- Monitor vital signs.
- Monitor the arterial pulse and capillary refill below an injury on the limb with swelling
- Refer the patient
Health Centre
- Immobilize injured limb by POP cast or splint
- Monitor vital signs
- Monitor the arterial pulse and capillary refill below an injury on the limb with swelling
- Consider anti tetanus prophylaxis according to the anti-tetanus protocol
- Refer the patient if open fracture or if specialist service not available
Hospital level
- Immobilize injured limb by POP cast or splint
- Monitor vital signs
- Monitor the arterial pulse and capillary refill below an injury on the limb with swelling
- Treat open fractures by proper surgical debridement and ORIF as per specialist guideline.
18.3.4 Spine fractures
Motor traffic injuries and falls constitute the burden of most spine injuries. Paralysis may be associated, often been brought by improper transfer of the patient to the hospital. Cspine injury is always accompanied by traumatic brain injury.
Diagnostic Criteria
- History of trauma
- Pain
- Neurological deficit
Investigation
- X-ray,
- CT scan and MRI are mandatory.
Non–Pharmacological Treatment
- Immobilize the neck by collar or pillows/sand bags
- Patient should lie flat in bed, preferably the flat bed or air mattress
- Treat shock as per the guideline
- Catheterize if urine retention
- Immediate transfer to the hospital that handles specialized spine surgeries
- Surgery of the spine often involves utilization of surgical implants such as plate, screws, rods, cage and transpedicular screws
Note: Examine cervical spine in all traumatic brain injury patients
