6.2 First Aid for Wounds, Burns, Fractures, and Hemorrhage

First Aid for Wounds, Burns, Fractures, and Hemorrhage

Prompt, accurate first aid interventions in the medical office reduce morbidity, prevent secondary tissue damage, and stabilize patients while emergency medical services (EMS) are dispatched. Medical assistants must master wound triage, bleeding control, burn surface estimation, fracture stabilization, seizure safety, and acute overdose management.

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Hemorrhage Control Protocol

Severe bleeding requires immediate, structured intervention to prevent hypovolemic shock and exsanguination.

Vascular Classification of Bleeding

• Arterial Bleeding: Bright red, pulsating or spurting blood under high pressure; rapid loss occurs; most severe and life-threatening.
• Venous Bleeding: Dark red or maroon blood flowing steadily; less pressure than arterial but volume loss can be substantial.
• Capillary Bleeding: Dark red blood oozing slowly from superficial tissue bed; easily controlled and often stops spontaneously.

Sequential Bleeding Control Steps

1. Direct Pressure: Apply firm, continuous direct pressure over the wound using a sterile gauze pad or clean cloth. Maintain pressure for at least 5 to 10 minutes without lifting the dressing to check the wound.
2. Elevation: Elevate the bleeding extremity above heart level while continuing direct pressure (provided no underlying bone fracture is present).
3. Pressure Bandage: Secure sterile dressings in place using an elastic or roller bandage wrapped snugly over the wound. Check distal capillary refill, sensation, and pulse to ensure circulation is not compromised.
4. Tourniquet Application (Last Resort for Extremity Arterial Hemorrhage):
   • Place a commercial windlass tourniquet 2 to 3 inches proximal to the wound site (never directly over a joint).
   • Tighten the windlass rod until arterial bleeding ceases and the distal pulse is completely impalpable.
   • Secure the windlass in the locking clip.
   • Document the exact time of application ("T = HH:MM") on the patient's forehead or tourniquet tag.
   • NEVER loosen or remove a tourniquet once applied; removal must be performed by surgical personnel in an emergency facility.

Wound Types, Tissue Mechanisms, and Treatment Protocols

Burn Classification and the Rule of Nines

Burns are tissue injuries caused by thermal, chemical, electrical, or radiation exposure. Assessment involves evaluating burn depth and calculating Total Body Surface Area (TBSA) involvement.

Burn Depth Classifications

• First-Degree (Superficial): Affects only the epidermis. Characterized by erythema, dryness, pain, and mild edema without blisters. Heals within 3 to 6 days without scarring (e.g., mild sunburn). Treatment: cool water immersion, aloe vera; avoid ice or butter.
• Second-Degree (Partial-Thickness): Extends through the epidermis into the dermis. Characterized by severe pain, deep erythema, edema, and fluid-filled blisters (bullae). Heals within 2 to 3 weeks. Treatment: cool sterile water compresses, non-adherent sterile dressing; do not pop blisters.
• Third-Degree (Full-Thickness): Destroys the entire epidermis, dermis, and subcutaneous tissue, potentially involving muscle and bone. Appears leathery, charred black, dark brown, or pale white. Painless at the center due to destroyed cutaneous nerve endings. Requires emergency fluid resuscitation, surgical debridement, and skin grafting.

Rule of Nines for Adult TBSA Estimation

The Rule of Nines divides the adult body into anatomical sections representing 9% (or multiples of 9%) of total body surface area:

• Head and Neck: 9% (4.5% anterior, 4.5% posterior)
• Anterior Trunk (Chest and Abdomen): 18%
• Posterior Trunk (Back and Buttocks): 18%
• Each Entire Arm: 9% (4.5% anterior, 4.5% posterior)
• Each Entire Leg: 18% (9% anterior, 9% posterior)
• Perineum / Genitalia: 1%

(Note: In pediatric patients, the head represents 18% and each leg represents 14% due to body proportions.)

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Fracture Immobilization and RICE Protocol

Fractures represent a disruption in bone continuity. They are classified as Closed (Simple) when skin remains intact, or Open (Compound) when bone fragments penetrate the skin.

Splinting Rules

1. Assess Neurovascular Status (PMS): Evaluate Pulse, Motor function, and Sensation distal to the injury site BEFORE applying a splint.
2. Immobilize Joint Above and Below: The splint must extend to immobilize the joint proximal and the joint distal to the fracture.
3. Do Not Force Re-alignment: Splint the limb in the position found unless distal pulse is absent and protocol permits gentle inline traction.
4. Re-assess PMS: Recheck distal pulse, motor function, and sensation AFTER splint application to confirm blood flow and nerve function are intact.

RICE Protocol for Musculoskeletal Injuries

• Rest: Immediately cease all movement and weight-bearing on the affected limb.
• Ice: Apply cold packs wrapped in a cloth barrier for 15 to 20 minutes every 2 hours during the first 48 hours to minimize edema and pain.
• Compression: Wrap an elastic bandage distally to proximally to control swelling without restricting arterial blood flow.
• Elevation: Elevate the injured extremity above heart level to promote venous return and fluid drainage.

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Seizure First Aid Protocol

Generalized tonic-clonic (grand mal) seizures involve abrupt loss of consciousness, bodily rigidity (tonic phase), followed by violent muscular contractions (clonic phase).

Emergency Actions

1. Protect from Injury: Clear surrounding area of furniture, hard objects, and sharp items. Place a soft folded jacket or pad under the patient's head.
2. Side Positioning: Turn the patient onto their side in the recovery position to facilitate oral drainage and prevent aspiration.
3. Time the Seizure: Record the exact onset and duration of seizure activity.

Absolute Contraindications

• Do NOT restrain the patient: Forcing movements can cause bone fractures or muscle tearing.
• Do NOT insert objects in the mouth: Inserting fingers, tongue depressors, or bite blocks can fracture teeth, block the airway, or cause severe bite injuries.

When to Call 911: Dispatch EMS if a seizure lasts longer than 5 minutes (Status Epilepticus), if a second seizure occurs immediately, or if the patient is pregnant, diabetic, or injured.

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Poisoning and Opioid Overdose Management

• Poison Control Center Hotline: National toll-free number 1-800-222-1222.
• Opioid Overdose Triad: Respiratory depression (<8 breaths/min or apnoea), pinpoint pupils (miosis), and unresponsiveness.
• Naloxone (Narcan) Administration: Administer 4 mg Intranasal Narcan into one nostril. Place patient in recovery position, activate EMS, and perform rescue breathing/CPR if pulseless. If no response after 2 to 3 minutes, repeat dose in the opposite nostril.