As with all trauma, assess the primary survey and manage any deficits. Analgesia is likely to be needed to help with any pain relief, considerations for fluid therapy, Tranexamic Acid for haemorrhage, oxygen, early extraction to hospital, and specialist/advanced support where appropriate to the situation and observations. Limb injuries can present in numerous different ways depending on the MOI and forces involved:
Compound fracture (open) – Where the bone has protruded through the skin, this can cause a number of complications such as haemorrhage, limb compromise, and risks for infection further down the line. The clinician must carefully manage the injury, looking at removing any gross contamination from the site, covering it with a saline soaked dressing followed with an occlusive layer, and repositioning any gross deformity into normal alignment with splintage, where possible.
If there is gross contamination, make a note of the nature of contamination as any realignment of the limb may cause it to be drawn inside. Do not irrigate the site as this may cause contamination to move deeper into the bones and tissues. Some Ambulance Services carry antibiotics which can be administered prophylactically to help prevent infection later on. Consider them and follow your local guidelines as per medication administration.
Closed fractures/dislocations – Closed fractures and/or dislocations can cause significant pain and distress to the patient. Closed fractures are where a fracture has occurred and hasn’t protruded through the skin, a dislocation is when a bone has come out of a connecting joint. These injuries may be obvious, with significant deformation to the limb, or not at all, with some pain in the area of injury. If there is no obvious injury or deformity, you must take into account the MOI, the surrounding circumstances, patients’ signs and symptoms, and other factors such as patients’ age, past medical history, any degenerative bone diseases, etc. On managing closed fractures or dislocations, a number of factors and actions need to be taken:
Amputations, partial amputations, and degloving – An amputation involves the complete severing of a limb, a partial amputation is an incomplete severing of the limb, and a degloving injury, also called an avulsion injury, is where the top layers of skin and tissue are ripped from the underlying muscle, connective tissue, or bone. When managing, remove any gross contamination from the site and cover with a saline soaked dressing followed with an occlusive layer. Where partially amputated, immobilise the limb in a position of normal anatomical alignment. Don’t irrigate the site in case of forcing contaminant deeper into the tissues and bones.
Reimplantation of a limb or reconstitution of a partial limb amputation may be possible depending on the injury, condition of the limb, affected limb, length of amputation time, and other factors. A limb kept in optimal conditions can possibly be reimplanted numerous hours following amputation. When looking at maintaining limb patency for possible reimplantation, remove any gross contamination from the severed site and cover with a moist dressing, secure the limb in a sealed plastic bag, and place the bag on ice. Make sure the body part isn’t directly touching the ice as this can cause tissue damage.
Laceration/Penetration injuries – Laceration and/or penetration injuries can range in severity depending on the MOI and factors involved. A simple laceration where there is no compromise to deeper tissues such as arteries/veins, tendons/ligaments, could be managed within a primary care setting with the use of Advanced Practitioners, or through Minor Injuries at Hospital. Where deeper tissues are affected, hospital admission will be needed to review the damage, and specialists will need to be involved to try and save the limbs’ function and ability.
On reviewing a simple laceration injury, remove any gross contamination and clean where possible. Place a saline soaked dressing on the wound to prevent any further potential contamination. Complete all assessments, observations, and paperwork, and review your pathway for further care and treatment. Some Ambulance Services may have pathways to follow which use Advanced Practitioners or Primary Care service, whereas others may not and a Minor Injuries Unit at hospital will be the only option.
Where deeper tissues are affected, the patient will require transport to Accident and Emergency for further assessment and care. Remove any gross contamination and place a saline soaked dressing. The wound may be bleeding due to deeper tissue damage. Follow the normal haemorrhage control actions to stop, i.e., applying the dressing with pressure over the wound site, and raise the limb above heart height.
Where there has been a penetrating injury, there is the potential for major bleeding to occur. Significant arteries and veins run through the limbs, and a severing of these blood vessels could lead to significant blood loss. If there is bleeding from a penetrating wound, follow the basic haemorrhage control steps to manage. If the haemorrhage continues and is unmanageable by basic means, or you feel the haemorrhage is of a catastrophic nature, follow catastrophic haemorrhage protocols: