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Emergency medical care of mass distruction

R.M. LyakhovychR.M. Lyakhovych

I.Ya. HORBACHEVSKY TERNOPIL STATE I.Ya. HORBACHEVSKY TERNOPIL STATE MEDICAL UNIVERSITYMEDICAL UNIVERSITY

Purpose of the organization and provision Purpose of the organization and provision of medical care at mass destructionof medical care at mass destruction

Значною проблемою у можливостіураження людей є масові заходиdanger of mass measures

http://www.aresnyc.org/Photos/SADD04/10_2_2004%209_54%20AM_0011.html

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Quantitative characteristics of injury:Trauma- injury of the body, its tissues or

parts caused by the influence of mechanic, physical, chemical or mental

factors, which is conducted with local and general reactions

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Isolated trauma- is a single injury at any anatomic and functional region of the body or organ.Multi-trauma- few injuries at one

anatomic and functional region.Associated trauma- few injuries, at

different anatomic and functional regions.Combined trauma- injury, which

appears as a result of simultaneous or sequential influence of several traumatic agents.

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Polytrauma- severe multiple and combined injuries, which cause the beginning of traumatic disease (wound dystrophy) and need immediate medical aid by life-saving indications.

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In case of associated trauma dominates the syndrome of mutual complexification, which means that every single injury might not be lethal, but together injuries might become life-threatening.

(Fracture+ rupture of intestine+ injury of liver, spleen)

Polytrauma is characterised with: syndrome of mutual complexification, atypical symptoms of damages, complicacy of diagnostic.

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“Traumatic disease” – is a phase of pathologic process, which gradually develops in case of severe injuries.Traumatic disease is usually divided into 4 periods:

I - shock II - period of early manifestations of traumatic disease III - period of late manifestations of traumatic disease IV - period of rehabilitation

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1. Subdural and epidural haematoma.2. Haemopneumothorax3. Splenic rupture4. Damage to the liver

Fracture of the pelvic bones or/and other injuries associated with large blood loss.

The third pick of lethality appears in few days or weeks after moment of injury and is usually connected with multiple organ failure and sepsis.

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Emergency medical aid is often provided in extreme conditions, when additional factors might harm not only patients, but also their

rescuers. In such cases medical workers should follow these rules:

1. Check the safety of the place of accident and if necessary ask professional rescuers or police to help. 2. Determine the quantity of victims, way of injuring, sources of danger in environment. 3. Define the necessity in additional emergencies in case of many victims.

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Components of emergency medical aid at the pre hospital stage:

Primary inspection ABCC’Medical sortingIntensive therapySecondary inspection (ABCDE)Constant observation of the patients conditionQualified and specialised medical help airwaysB-breathingCirculationC’- cervical spine- with using of neck collar

№ Name of the limb or its segment and length of the limb

Anatomic points Comment

Proximal Distal

1 2 3 4 5

1 Upper limb (total length) The edge of the acromial process

The apex of the styloid process of the ulna

The arm is completely extended in the elbow

2. Brachium (anatomic length) Greater tubercle of the humerus

Lateral epicondyle of the humerus

–

3. Forearm (anatomic length) The apex of the tip of the elbow

The apex of the styloid process of the ulna

The forearm is flexed at right angel in the elbow

4. Lower limb (total length) Spina iliaca anterior superior

The apex of the medial malleolus

The lower limb is completely extended

5. Femur and hip joint (total length)

Spina iliaca anterior superior

Joint line on the medial side of the knee

–

6. Femur (anatomic length) The apex of the greater trochanther

Joint line on the lateral side of the knee

–

7 Tibia (anatomic length) Joint line on the medial side of the knee

The apex of the medial malleolus

–

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Classification of shock

Degree of Degree of shockshock

Blood pressureBlood pressure Pulse per Pulse per minuteminute

1 1 degreedegree 90-10090-100 90-10090-100

2 2 degreedegree 90-7590-75 110-120110-120

3 3 degreedegree 75 75 and lessand less OverOver 130130

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Open fracture of bones of forearm

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Probable complication of fracture or transportation without immobilisation

Mechanism of radial nerve damage

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Splintered open fracture of both bones of right forearm at the level of lower 1/3

Combined MOS

1 2

3 4 5

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Fractures of the pelvis

A.B. Fractures of the wing of

ilium

C.D. Fractures of sacrum

E. Fractures at the level of

iliosacralis articulation

F. Fractures of ishiadic and

pubic bone

G. Fracture of pubic bone

(horizontal ramous)

H. fracture of ishiadic bone

I. Fracture of pubic articulation

Without breaking of pelvic circle continuity

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With breaking of pelvic circle continuity (Malign)

1. Fracture at iliosacralis articulation with dislocation.

2. Fracture of pubic bone with dislocation.

3. Fracture of the ischiadic bone with dislocation

1

Fracture-displacement of half-pelvis

Fracture of pelvic and iliosacralis articulation with dislocation of pelvic circle

Fractures of the pelvis

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Fractures of the pelvis

Mechanisms of injury- direct and indirect

Clinic: pain, deformation of the pelvic circle, specific position of the limb, depends on the type of fracture, pathologic mobility.

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Transportation of the patient with pelvic fracture

Patient with pelvic fracture should be transported on the

stretcher in position with flexed (30º-40º) knees and

femoral articulation (abduction 10º). This position is the

most physiological for the muscles, which are connected

with the pelvis and doesn’t cause additional dislocation

(so called “frog-position”).

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Shaft of femur fractures

Fractures of this localisation consist 40% of all femoral fractures.

Mechanism of the trauma: direct and indirect

There are fractures of upper, middle and lower 1/3 of femoral bone.

Clinic: pain, oedema, pathologic mobility, bone fragments crepitating.The specific feature of this trauma is often development of trauma shock and blood loss (0,5-1,5 l), and if the patient is transported without immobilisation, the risk of fat embolism growth.

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Clinical examples

Combined trauma: fracture of heel bone+burns (treatment- mod apparatus of Elizarov with compression of bone fragments)

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Displacements of footSubtalar open displacement of the foot

Passive postural position

Passive postural position

3939a - immobilisation with Cramer's splint in case of crus’ fractureb - immobilisation with Diterichs' splint

Transporting immobilisationThe main principle is the immobilisation of joints, which are above

and lower than fracture

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Use the rule of 4 catheters:Nasal for oxygenGastric for evacuation of its contents (when patient is unconscious)Intravenous for infusionsUrinary for measuring of diuresis

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Glucocorticoids in case of hypovolemic shock.Immobilisation of fractures- standard and improvisational

splints, contra shock clothes.A/B therapy, beginning from “wide” antibiotics (cyfran,

zanocyn, cephalosporins).Prevention of supercooling- warm coats, the optimal

climate control, warm liquids for drinking (except abdominal trauma), warm infusion solutions 35º- 40º.

Symptomatic syndromes and corrective therapy.

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Transportation of patient with polytraumaTreatment of patients at pre hospital stage needs

experienced medical workers and expensive medical equipment. Every delay might cause life-threatening

complications. Those statements cause the necessity of hospitalisation of such patients to the specific in-patient departments, where exists the possibility to involve into treatment surgeons, neurosurgeons,

traumatologists, anaesthesiologists.

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All victims with polytrauma should be hospitalized to the intensive care department

or antishock ward.

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Many thanks!Many thanks!