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OBJECTIVES:
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1. To control external bleeding
2. To prevent further injury and reduce pain
3. To prevent further wound contamination and reduce the potential of subsequent infection
4. To secure dressings through the application of appropriate bandaging techniques
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GENERAL PRINCIPLES:
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1. Use appropriate body substance isolation precautions
2. Expose the wound site to determine the extent of injury
3. Control bleeding by using the following techniques as needed: direct pressure, pressure dressing, elevation, pressure points, cold application and tourniquet
4. Use sterile dressings
5. Cover the entire wound site with the sterile surface of the dressing
6. Apply bandage snugly, making certain not to cut off circulation distal to injury site
7. Secure the dressing(s) with roller gauze or cravats applying gentle, even pressure over the wound site
8. Use the patient’s brow ridge, chin and occipital ridge as necessary to provide natural anchoring points for bandaging
9. If the chin is used, monitor the patient carefully for airway problems. Cut bandage and fold flaps up if bandage interferes with airway or causes patient discomfort
10. Immobilize the injury site as appropriate
11. Consider shock and prevent/treat as appropriate: oxygen, patient positioning, maintenance of body temperature
12. CMS should be checked frequently and bandaging adjusted to maintain a pulse if necessary
13. Always consider the Mechanism of Injury (MOI)
14. Suspect cervical spine injury with significant MOI
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I. HEAD
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IMPORTANT POINTS:
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1. Do not exert point pressure to scalp if underlying fracture is suspected
2.. Do not pack nose or ear to stop blood or cerebral spinal fluid (CSF) flow
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SKILLS:
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A. HEAD (side wound)
1. Open dressing to preserve sterile surface
2. Apply sterile surface to wound site and control bleeding
3. Anchor bandage securely under brow and occipital ridges
4. Cover dressing completely with bandage
5. Exert even pressure over entire wound site with finished bandage
6. Leave eyes uncovered; leave ears either completely covered or completely uncovered
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B. HEAD (top wound)
1. Open dressing to preserve sterile surface
2. Apply sterile surface to wound site and control bleeding
3. Anchor bandage securely under brow and occipital ridges
4. Bring bandage over dressing and under chin and tighten down over dressing
5. Cover dressing completely and apply even pressure with bandage over area
6. Anchor bandage securely by making additional wraps around head, securing under brow ridge and occipital ridge
7. Cut bandage under chin and fold ends up if it interferes with the airway
8. Make last few turns around brow, overlapping folded section
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II. EYE
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IMPORTANT POINTS:
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1. If areas around eye are lacerated but the eyeball is not involved, use direct pressure to control bleeding
2. If eyeball injury is suspected, close eye and apply loose dressing
3. If chemical burn is involved, irrigate eye with normal saline continuously
4. If thermal burns are involved, apply dressing moistened with sterile saline solution
5. If light burns are involved, cover eyes with moist, lightproof pads
6. Cover both eyes when injury occurs as consensual eye movement may cause further injury
7. Never touch the globe or the penetrating object with your hand
8. The finished bandage should hold the eye and/or penetrating object in place
9. Maintain verbal and physical contact with the patient as you explain your actions
10. Always irrigate from the bridge of the nose outward in order to avoid infecting or contaminating the uninjured eye
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SKILLS:
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A. EYE INJURY – Non-penetrating
1. Have patient close eyes
2. Apply sterile surface of dressing to injury(ies)
3. Secure bandage around head, anchoring under occipital ridge
a. Bandage snugly if eyeball is uninjured
b. Bandage loosely if injury to the globe is suspected
4. Cover both eyes with finished bandage; do not occlude mouth or nose
5. Restrain patient’s hands to keep from touching the eye area as needed
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B. EYE INJURY – Penetrating
1. Surround injured eye with sterile padding
2. If penetrating object, cut hole in end of cup just large enough for object to pass through
3. Place cup or cone over eye, resting it on pads, but do not touch the eye
4. Secure the cup/cone to head with bandage wrapped around cup and then around head anchoring on occipital ridge
5. Wrap bandage to cover uninjured eye, leaving the nose and mouth exposed
6. Restrain patient’s hands as necessary to prevent patient from touching the bandaged area
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Do not cut a hole in dressings or padding as it may leave small particles of fabric in the eye
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III. NECK
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IMPORTANT POINTS:
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1. Use an occlusive dressing to prevent air embolus from being sucked into jugular vein
2. DO NOT use a circumferential bandage around the neck
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SKILL:
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1. Place dressing over wound
2. Secure dressing in place by wrapping the bandage over the dressing and over the top of the opposite shoulder, crossing under the axilla and back again to form a figure eight
3. Unless contraindicated, transport patient on left side in moderate Trendelenberg position
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IV. TORSO
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IMPORTANT POINTS:
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1. Chest injuries can be life threatening and must be assessed and treated immediately
2. Penetrating objects should be left in place unless they interfere with the patient’s ability to breathe or maintain an airway
3. Penetrating objects must be removed if CPR is necessary
4. All open or penetrating injuries to the chest or abdomen must be sealed with an occlusive dressing
5. Large penetrating objects should be shortened to facilitate transport or provide stabilization
6. Control bleeding with direct pressure around organs, never on top of them
7. Look for multiple entry/exit wounds with any form of penetrating trauma
8. Use sterile solution soaked dressings on protruding organs
9. Administer high flow oxygen and assist ventilations as appropriate
10. Transport patients rapidly to the closest appropriate medical facility
11. Consider ALS intercept early where available
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SKILLS:
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A. OPEN CHEST (SUCKING CHEST)
1. Immediately apply manual pressure to seal wound after patient forcibly exhales
2. Apply and secure an occlusive dressing,
3. Auscultate for breath sounds
4. Closely monitor patient for signs of deterioration
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B. PENETRATING OBJECT
1. Stabilize object with hand(s)
2. If in chest, upper abdomen or neck area , apply occlusive dressing surrounding the base of the object
3. Stack bulky dressings in alternating layers to stabilize object from all sides
4. Secure dressings with bandage to control bleeding and immobilize the object
5. Restrain patient’s hands as necessary to prevent patient from removing object
6. Transport rapidly in position of comfort
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C. ABDOMINAL EVISCERATION
1. Cover exposed or protruding organs with a sterile dressing moistened with sterile saline
2. Cover with occlusive dressing to prevent moisture loss
3. Cover with bulky dressings to preserve body warmth
4. Secure dressings loosely in place
5. Transport patient in supine or lateral recumbent position with knees flexed
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D. SHOULDER
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IMPORTANT POINTS:
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1. May be accompanied by fractures or dislocations
2. Suspect C-spine injury with significant MOI
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SKILL:
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1. Apply sterile dressing to wound and control bleeding with direct pressure
2. Check CMS distal to injury prior to applying bandages
3. Position forearm flexed across chest and bring upper arm along line of body
4. Wrap bandage around body, covering wounded arm and crossing under arm on the uninjured side to secure dressing
5. Recheck CMS distal to injury
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E. AXILLARY
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IMPORTANT POINTS:
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1. Dressing of axillary wounds can easily impair circulation. Check CMS often
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SKILL:
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1. Apply sterile surface of dressing to wound and control bleeding with direct pressure
2. Check CMS distal to injury prior to applying bandages
3. Add dressings over the first to achieve bulk as necessary
4. Bandage around injured armpit and shoulder
5. Position forearm flexed across chest, hand pointing toward opposite shoulder. Recheck CMS
6. Wrap bandage around body, over outside surface of arm on injured side and under opposite shoulder
7. Recheck CMS distal to injury
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F. EXTERNAL GENITALIA
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IMPORTANT POINTS:
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1. Preserve the patient’s privacy
2. Expose genitalia only if wound is suspected
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SKILL:
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1. Apply sterile dressing to wound site and control bleeding
2. Secure the dressing by running a bandage over dressing, between legs and around pelvis.
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V. EXTREMITIES
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IMPORTANT POINTS:
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1. Remove patient’s jewelry from the affected extremity
2. Elevate extremity to reduce pain and control bleeding, if circulation is present
3. Leave digits exposed whenever possible
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SKILLS:
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A. HAND
1. Check CMS
2. Apply sterile surface of dressing to wound and control bleeding
3. Place bandage roll or dressing in palm of hand to maintain position of function
4. Anchor bandage around wrist
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5. Wrap hand to prevent release from position of function
6. Achieve some restriction of wrist joint movement with bandage
7. Place hand in elevated position
8. Recheck CMS distal to injury
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Leave fingertips exposed to check CMS
Consider use of splint to restrict movement
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B. AMPUTATION/AVULSION
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IMPORTANT POINTS:
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1. Save all amputated or avulsed parts. Transport with patient whenever possible
2. Wrap in a sterile dressing
3. Protect in watertight container
4. Keep part(s) cool during transport, but do not allow to freeze
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Dry or moist dressing per local protocol
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SKILL:
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1. Apply sterile dressing to wound and control bleeding with direct pressure
2. Wrap bandage around circumference of extremity and pass bandage several times across end of stump to achieve pressure over bleeding area, then secure with several additional circumferential turns
3. Keep stump elevated, if possible
4. If partially attached:
a. Fold skin flap back over wound
b. Secure with sufficient pressure to control bleeding
c. Keep partial amputation cool
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VI. BURNS
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IMPORTANT POINTS:
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1. Make certain the scene is safe to enter
2. Always take appropriate hazard precautions as well as body substance isolation precautions
3. Burns involving the hands, feet, face or genitalia should be considered critical burns
4. Any burns associated with respiratory injuries are critical injuries
5. Burn patients are especially susceptible to shock (hypoperfusion) and hypothermia.
6. Care must be taken to minimize the potential for infection when dealing with burn patients
7. Never use any type of ointment, lotion or antiseptic
8. Avoid breaking blisters
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SKILLS:
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A. THERMAL BURNS
1. Stop the burning process as rapidly as possible using water or saline
2. Remove jewelry and any easily removable clothing or debris from the affected area
3. Continually monitor the airway and breathing for signs of airway impairment or respiratory distress
4. Prevent further contamination of the burned area
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5. Cover the wound with a clean and dry dressing
6. Treat for shock
7. Transport
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Avoid dressings that may leave fragments in burn injuries
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B. ELECTRICAL BURNS
1. Do not attempt to remove a patient from the electrical source unless trained to do so
2. Do not touch a patient unless you are certain s/he is no longer in contact with the electrical source
3. If appropriate, and after assuring no electrical threat remains, stop the burning process as rapidly as possible using water or saline
4. Remove jewelry, and any easily removable clothing, or debris from the affected area
5. Continually monitor the airway and breathing for signs of airway impairment or respiratory distress
6. Prevent further contamination of the burned area
7. Treat any soft tissue injuries or fractures associated with the burn. Look for multiple entry/exit wounds
8. Cover any exposed burned area with a dry, sterile dressing
9. Treat for shock
10. Transport
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C. CHEMICAL BURN
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1. Always consider the potential impact of hazardous materials. Patient(s) should not be transported until primary decontamination is completed
2. Brush dry powders off prior to flushing
3. Remove jewelry and any easily removable clothing or debris from the affected area
4. Flush the affected areas with large quantities of water or saline
5. Continue flushing the contaminated area(s) during transport
6. Do not contaminate uninjured or unaffected areas while flushing
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Refer to Emergency Response Guidebook or other resources
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7. Continually monitor the airway and breathing for signs of airway impairment or respiratory distress
8. Prevent further contamination of the burned area
9. Treat any soft tissue injuries associated with the burn
10. Treat for shock
11. Transport
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