LECTURE NOTEBOOK

ON

INTRODUCTION TO ACCIDENT AND EMERGENCY

FOR

COMMUNITY HEALTH EXTENSION WORKER’S STUDENT

Compiled by

MUHAMMAD YAKUBU MUNKAILA

CHE (2014), DHE (2015) AND B.SC (Ed) HED (2019), M.Sc (Ed) HED (2023).

2023/2024

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WHAT IS FIRST AID
It is the initial skilled assistance or help given to an injured person or someone who suddenly
taken ill before the arrival of medical aid or taken to hospital. In other words informed
knowledge, skills and techniques with a bright idea on what to do, how to do, when to do and
where to do. In a nutshell first aid is the combination of kills and practical common sense.
WHY WE GIVE FIRST AID
1. To Preserve life
2. To Limit the condition from becoming worse
3. To Promote recovery

TO PRESERVE LIFE
 Assess the casualty
 Airway (open)
 Breathing ( check)
 Chest compression
 Control bleeding

TO LIMIT THEWORSENING OF CONDITION

 Examination of the casualty
 Make diagnosis
 Give priority to seriously injured
 Consider possibility of secondary condition

TO PROMOTE RECOVERY
 Relieve discomfort, pain or anxiety
 Reassure the casualty
 Get medical aid as fast as possible

FIRST AID PRIORITY

 Do not panic
 Keep away from any danger
 Assess the situation
 Waste no time in summon help
 Do nothing if in doubt
 Comfort and reassure
 Stay with the casualty until help arrives

BEING A FIRST AIDER

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  Assessing risk
 Doing your best
 Giving care with confidence
 Being in control
 Being gentle but firm
 Building trust

TREATMENT PRIORITY
1. Assess for consciousness
2. Breathing
3. Bleeding
4. Burns
5. Broken bones
6. Others

ACTION AT AN EMERGENCY
D = Danger
R = Response
A = Airways
B = Breathing
C = Compression
D = Defibrillation
DANGER
 Check for any Danger
 Deal with Danger to yourself, bystanders and casualty
 Is the area safe?

RESPONSE
 Check for responsiveness
 Try to get response by asking questions and gently shaking casualty shoulder

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AIRWAY
 If no response
 Shout for help
 Open the AIRWAY
 Gently tilt the head backwards and Lift the chin

BREATHING
 Check for BREATHING
 Keep the airway open look, listen and feel
 Look for chest movement
 Listen to sound of breathing
 Feel for breath on your cheek
 Do this for not more than 10 second

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IF BREATHING IS PRESENT
 Place in RECOVERY POSITION
 Aims: mouth low, jaw forward chest up the ground and casualty stable

IF BREATHING IS NOT PRESENT

 Chest compression
 Call for help
 Commence 30 chest compression immediately

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  Attempt 2 rescue breathe
 30:2 ratio

IF BREATHING IS NOT PRESENT

1. One hand and two fingers

2. Continue at ratio of 30 compression to 2 breaths

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3. Pinch the nose of adult and child, for infant cover both nose and mouth at the same time with
your mouth

AUTOMATED
EXTERNAL DEFIBRILLATOR
An (AED) Automated External Defibrillator is a device that sends an electric shock to the heart
that will restore the natural heart rhythm to the victim during a cardiac arrest.
SEQUENCE OF AED INSTRUCTIONS
 Switch AED on
 Attach pads to casualty’s chest
 AED gets ready to analyze the casualty heart rhythm
 Is the shock advised?
 If yes the machine charges up
 AED instructs you to deliver the shock ( All stay clear)
 Push the shock button AED delivers the shock
 AED instructs you to carry out CPR for two minutes before it re - analyses
 If NO shock is advise
 AED will instructs CPR to be carry out again

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Note: The machine is user friendly
CAUTION!!!
• Make sure that no – one is touching the casualty
• Do not turn off the AED or remove the pads at any point
• It does not matter if the AED pads are reversed
• Shave casualty‘s chest with much hair
• Wipe away sweat from the casualty chest
• Never use an AED on an infant under one year

MANAGEMENT OF WOUNDS
Wound is a breach in the continuity of the tissues of the body, either internal e.g (contusion)
external e.g incision from various agents.
Enumerate the classification of wounds as:
1. Open wound: This is a break in the skin or mucous membrane e.g. abrasions puncture
wound e.t e
2. Closed wound: This involves injury to underlying tissues without a break in the skin or
mucous membrane e.g contusion or bruise.
Identify the causes of wounds as:
1. Mechanical agents:
Most are the result of some mechanical injury sustained at work, in the home, on the road of the
result of assault. The wounds so produced are of different types:
 Incised
 contused
 Punctured
 Lacerated
2. Chemical agents:

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These are usually strong acids, alkalis or other caustic and corrosive chemicals which
accidentally come in contact with tissues. Epithelial tissues take the brunt of this e.g. the
cutaneous wounds from acid burns, skin narcosis accompanying snake or insect bites.
3. Radiant energy:
Radiation in its various forms - X-rays radium, and other forms of atomic energy, heat and
intense cold - produce extensive wounds notable for the degree of tissue necrosis entailed.
4. Pathogenic micro-organism:
Owing to the natural capabilities of the integument's to resist invasion, pathogenic organisms by
themselves seldom cause wounds, more often they are the secondary invaders of wounds
produced by other primary agents. The extensive tissues necrosis arising from bacterial invasion
is usually effected through chemical substances, c.g. exotoxins. Tissue destruction may be also
be produced through a hypersensitivity reaction by the local tissues to the organism.
The different types of wound:
Abrasion:
Means mere loss of the epithelium. This usually occurs when the skin is scraped against a hard
surface.
 Bleeding is limited.
 Danger of contamination and infection exists (secondary infection)

Incision:
Means when body tissue is cut with a sharp knife, broken glass or other sharp objects.
 Bleeding may be rapid and heavy.
 Deep cuts may damage muscles, tendons and nerves.
Lacerations:
A lacerated wound displays jagged, irregular, or blunt breaking or tearing of the soft tissues and
is usually caused when great force is exerted against the body.
 Destruction of tissue is greater in a lacerated wound than in a cut.
 Bleeding may be rapid and extensive
 Deep contamination of the wound increases the chance for later infection.
Puncture:
A puncture wound is produced by an object piercing skin layers, creating a small hole in the
tissues. Puncture - producing objects, such as pins, nails, and splinters. External damage may
occur to the organs causing internal bleeding.
 The hazard of infection is increased because the flushing action of external bleeding is
limited.
 Tetanus may develop.

Avulsion:
An avulsed wound results when tissue is forcibly separated or torn from the victim’s body.
 There will be heavy rapid bleeding
 An avulsed body part may be successfully surgeon. Therefore endeavor to send to send
the body part along with the victim to the hospital
 Avulsed wounds occur in accidents such as motor vehicles wrecks, explosions, animal
bites and other body - crushing injuries.

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Wound healing is the process whereby the body replaces damaged tissue with living tissue, in
human beings, the healing process has two aspects:
(1) Muscles Contraction: a mechanical reduction in the size of the defect occurring in the first
few weeks.
(2) Replacement of lost tissue: which is brought about by migration of cells as provide extra
tissue to fill the defect created by the injury. This can be accomplished in two ways:
a. Regeneration: This term is used to describe the process whereby lost, specialized tissue is
replaced by proliferation of surrounding undamaged specialized cells eg bone marrow,
b. Repair: This means the replacement or lost tissue by granulation tissue which matures to form
'scar tissue. This is inevitable when the surrounding, specialized and replace the lost tissue of
muscles and neurons.
The factors affecting wound healing are:
(1) Age: Wound healing is that in the young but is normal in old age unless there is some
associated debilitating disease. This is because protein turnover reduces with age and this is
reflected by a slow rate of healing.
(2) Blood supply: Wounds of the face and hands, however horrifying on first appearance heal
because of an excellent blood supply. Wounds below the knees, over the shin and call - notably
in the elderly - heal badly because of relatively poor blood supply.
(3) Malnutrition: This has been associated with the defective synthesis of both collagen and
ground substance. Severe protein caloric malnutrition has long been implicated in the failure of
wounds to heal, while similarly lesser degrees of malnutrition depress healing.
(4) Vitamins: Vitamins C: Wounds healing is notoriously slow in scurvy and even healing
wounds or fractures break down again. Vitamin C is necessary for synthesis of ground
substances and malnutrition of collagen. Vitamins D: Is essential for bone formation and
vitamin. A for formation of epithelium.
(5) Infection; Infection is a major factor in the failure of wounds to heal.
(6) Steroids: - depress wound healing, by their anti-inflammatory action to their anti-
inflammatory agent.
(7) Radiation: - Radiation cause ceil death both by damaging DNA and by disrupting intra-
cellular metabolisın.
The different dressing materials
 Skin docs not tolerate constant moisture and whatever type of dressing is used. It is
preferable that it should provide ventilation to the underlying skin.
 Gauze: - This is made of cotton or rayon in various qualities depending on the number of
threads per cm. It is son, absorbent and pliable. The gauze layer in a dressing provides a
sterile porous barrier between the wound itself and the overlying wool, bandage or
adhesive strapping there are also gauze rolls and ribbon used for temporary packing to
control bleeding or use in the vagina or abdominal cavity during operation also used as a
light packing in cavities or to provide a wick-type of drainage.
 Cellulose tissues: This is supplied in rolls in the same way as colon, it is very absorbent
and disintegrates, when wet. It is cheap and elective outer packing when large quantities
of exudate or discharge need to be absorbed. I should never be placed immediately over
the gauze layer as bits of the fibre may become detached and enter the wound,
 Gamgee: - This is a trade name for a layer of cotton wool enclosed in surgical gauze. In
hospital practice, squares of gamgee are used for placing over large dressings as it does

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 not become as lumpy as simple cotton wool. The material is also very suitably shaped
pieces are gently bandaged around the limbs and trunk.
 White lint: - The soft flannel-like material is not used extensively as dressings. It is
suitable for such items as out-out face mask or eyes-shield to protect a burnt or ulcerated
face.
First aid treats for open wound.
(a) Stop the bleeding immediately by applying firm pressure with clean dressing and elevation of
affected part.
(b) Protect the wound from contamination and infection.
(c) Provide shock care
(d) Transfer quickly and carefully to a centre where definitive treatment can be given

BLEEDING
Bleeding is the loss of blood from the vessels that make up the circulatory system. These vessels
are known as arteries, veins and capillaries. There are two forms of bleeding, external and
internal. External bleeding is obvious, whereas internal bleeding is more difficult to detect.
MANAGEMENT OF SEVERE EXTERNAL BLEEDING
 Put on gloves if available or find a covering for your hands
 Inspect the wound to ensure there are no objects embedded
 Apply direct pressure (clean bandage/pad) on the wound
 Lie the casualty down and elevate the affected area, if injuries permit
 Ensure once applied that the bandage is not too tight and there is good circulation beyond
the bandage
 For minor wounds, Clean and cover

No foreign object embedded in wound.

1. Expose the wound.
2. Apply direct pressure.
3. Do not remove any embedded object

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BURNS
Definition: - A burn is defined as destruction of the skin, sometimes including the deeper tissue
caused by dry heat, electricity, chemical and irradiation
Scald: A scald is a burn caused by moist heal cu steam and hot liquid.

First Aid Management at site of burn

Burn and scalds: Remove patient from source of local and extinguish tames. The burned area is
kept under running cold water if available or cold clean water soaks are applied and removed
every few minutes
Electrical burns: - Switch off electrical supply. If the victim is unconscious exclude cardiac arrest
and if necessary apply cardio-pulmonary resuscitation
Chemicals burns: irrite the affected areas with a lot of clean water, the burn part is then covered
with a clean sheet or towel vice or two and the patient quickly and carefully transported to the
hospital. At the severity of the burn wound is determined. This depends on:
1. Extend of body surface burnt
2. Depth of burn
Estimation of the extent of burns:
The body surface area involved is estimated by rule of nines of Wallace, by this method of
calculating body surface area involved,
 the head and neck is 9 %,
 the two upper limbs is 9 %,
 the front of the trunk is 15%,
 the perineum (genital area) is 18
 Making a total of 100% the role of the nines is not very accurate and only applies to
adults. In children the head and the neck made up about of 20% of the total body surface
area.
Depth of burns: -
Burns arc classified according 10 depth of involvement of the skin and underlying issue into
partial and full-thickness buns.
(1) Partial thickness burn: Here only part of the skin is involved: it any be
(a) Superficial partial thickness also known as 1" degree burn when only the epidermis is lost or
(b) Deep partial thickness also known as 2" degree burn when the skin as far as the deep dermis
is lost
(2) Full thickness or 3 degree burn is when the whole of the skin is lost Structures deeper than
skin eg fat, fascia, muscle or even bone may also be burst

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Treatment of burns:
 Relief of pain Full thickness burns are relatively painless due to destruction of nerve
endings, Partial thickness burns are quite painful. Small intravenous doses of morphing or
chlorpromazine may be given to relieve pain and allay anxiety,
 Replacement of fluids - The volume of fluid lost will depend on the extent of the body
surface but, Burns patient requires intravenous resuscitation if their injury exceeds 10%
body surface area in children or 15 in adults. If a smaller area is involved, oral
rehydration therapy is adequate
 Tetanus Toxoid Booster. Should be given in all cases, a 5 day course of penicillin is
given for prophylaxis in patients with extensive wounds. If infection becomes
established, the organism is identified from culture, its sensitivity determined and
appropriate antibiotics given
 Nutrition Support. There is an increase in nutritional demands (calories and protein) in
burns patients, hence this additional demand most be provided for to aid bum wound
healing, Vitamins especially B&C and minerals Sodium, potassium, Magnesium and iron
must all be given in adequate amounts.
 Care of the burn wound: - The wound is cleaned with antiseptic solution eg 1% cetrimide
or bland soap and warm water, blister are Ion alone but dirt and loose devitalized tissues
are removed. The wound is either le exposed or covered with dressings,
(1) Exposure method (no dressing: Gentian violet solution is applied to clean the bum
wound. This method is well suited for the treatment of burns of the face and perineum
(2) Dressing
(a) Occlusive dressing can be used to cover burn wounds. Being occlusive, prevents bacterial
contamination but must be absorptive to absorb exudate. To prevent pain and bleeding during
change of dressing, non-adherent dressing Bike Vaseline uure or sofratulle is used next to the
wound before applying the occlusive dressing. An antibiotic cream is also applied locally
(b) Silver nitrile dressing: - 0.5% silver nitrate dressing is effective in the prevention or treatment
of pseudomonas pyocyanae contamination of the local burn wound. More extensive burn wounds
might require skin grafting and should be referred to a. plastic surgeon

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Complications
 Hypovolacmic Shock
 Infection
 Gastric intestinal bleeding
 Cardio-respiratory problems eg pneumonia, atelcetasis
 Genito-urinary problems cg renal failure
 Vascular problems eg deep vein thrombosis.
 Deformities and contractures
 Psychiatric Problems
 Kcliods and hypertrophic scars

SHOCK
A clinical manifestation of inadequate blood and oxygen supply to the tissues resulting from a
reduction in effective circulating blood volume.
Types and causes of shock
 Hypovolaemic Shock - Shock caused by a reduction of actual blood volume and may
result from:
(1) Acute Hacmaorrhage: (Haemorrhagic shock) which may be internal eg due to ruptured
spleen, ruptured tubal pregnancy, haemothorax or external bleeding eg due to bleeding peptic
ulcer, open wound, abortion, or may occur in the soft tissues eg crush injury, closed fractures.
(2) Low of plasma which could be us a result of extensive fluid or peritonitis
(3) Loss of extracellular fluid as occurs I intestinal, obstruction, diarrhea, peritonitis and
vomiting
 Cardiogenic Shock: (Failure of cardiac pump) which may due to impaired function of
the heart, causing a reduction in cardiac out-put and so reduced effective circulating
blood volume. It can occur in myocardial infection, cardiac tamponade and pulmonary
embolism.
 Septic - (Endotoxic shock) caused by micro-organisms.
 Anaphylactic shock: - hypersensitive reaction occurring within seconds of injection of
animal scrum or drugs including antibiotics.
Usually there is a generalized vasodilation of peripheral vessels and constriction of result
bronchioles and edema of larynx.
 Neurogenic Shock: - (Vassvagal syndrome) due to vasodilation of arterioles and
venules which follows sudden exposure to unpleasant events such as pain or fright. It
may result from spinal anesthesia.
Signs and symptoms of shock:
 Pulse is rapid and steady
 Breathing is rapid, sighing and shallow (air hunger)
 Skin becomes cold and clammy to touch and is either very pale or grey in colour.
 Core temperature is high, up to 39 °C

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  Peripheral veins collapse
 Blood pressure will be lower than normal
 Patient is confused, restless, apathetic or comatose
 Vision is blurred
 There is decreased consciousness
 Decreased urinary output.
The general management of shock:
1. Lay the patient down cither in bed, on the floor or where the accident occurred.
2. Place patient in the prone position with head turned to the side if possible or place patient
on his side.
3. If possible raise the lower part of the body, to help the now of blood the brain.
4. If patient is indoors, simply cover him with a light blanket but do not overheat or make to
sweat.
5. Undo tight clothing round neck, chest and waist, and make sure the patient is not
crowded by spectators.
6. If patient is conscious, reassure him by appealing calm and self-confident.
The management of specific types of shock as follows:
1. Hypovolcanic Shock:
 Control bleeding: If there is an external wound which is bleeding, a firm sterile dressing
should be applied.
 Elevation of the logs- these increases venous return from the legs thereby increasing
cardiac output.
 Replacement of fluids- with either crystalloid e.g normal saline, blood or blood
substitutes e.g dextran
 Drugs eg Morphine lo relieve pain
 Oxygen is administered' via a plastic nasal catheter or oxygen mask to increase the
oxygen saturation of the blood.
2. Anaphylactic Shock:
 Adrenaline is most effective, given as specified in this standing orders.
 Give antihistamine is response to adrenaline is not rapid
 Hydrocortisone is also given as specified in the standing orders
 Given aminophylline or saline according to the standing to relieve bronchospasm
 Adequate airway must be provided and intravenous fluids administered rapidly.
 Septic shock: Refer patient.
3. Neurogenic shock.
 Lay patient flat with the head low, the patient will usually recover, by this maneuver

Signs of recovery from shock as follows:

 Pulse becomes slower and stronger
 Skin feels warmer and regains its colour
 Respiration is slower and deeper
 Increased consciousness.
 Decreased restlessness
 Peripheral veins distend
 Increased urinary output
Causes of death in shock

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  Pulmonary insufficiency
 Cardiac failure or arrest
 Cerebral failure
 Pre-renal failure
 Metabolic acidosis
 Gram-negative septicemia.

CIRCUMCISION
Define circumcision as the surgical removal of the prepuce (fore skin) around the glans penis.
State reasons for circumcision as:
 Social reasons
 Religious reasons
 Medical reasons such as:
a. Phimosis, i.e. a tight fore skin,
b. Balanitis, i.e in Nammation due to lack of cleanliness
c. Paraphimosis, i.e. a condition due to tight force skin being pushed up and constricting
the circulation causing swelling of the parts below so that the fore skin cannot be
pushed down again.
The methods of circumcision:
Using conventional surgical method
The instrument used in circumcision as:
 A tray
 3 artery forceps
 A pair of scissors
 Suture needles • sutures eg. catgut, chronic catgut
 Antiseptic solution e.g. Savlon, Hibitane gauze swabs, TBC.

PROCEDURES
 With patient in the supine position on operating table and an assistant holding the patient
to restrict movement in infants, (in adult, general anesthesia is required).
 A dorsal slit of the prepuce is carried out almost to the corona and the redundant prepuce
excised on each side. Hemostasis is secured.
 In an infant, the prepuce is first freed from the underlying glans using a probe if
necessary.
 It is taken retracted and smegma on the glans and corona cleaned with antiseptic solution.
 The prepuce is then drawn forward and grasped with two pairs of forceps held by an
assistant.
 A bone cutting forceps with the flat surface towards the operator is then applied obliquely
across the prepuce just beyond the glans so that more skin is removed dorsally than
ventrally.
 The tip of the glans is protected between the thumb and index finger as the bone forceps
is applied. The prepuce is then divided cleanly with a knife in front on the bone forceps.
 The bone forceps, which crushes the skin and occludes the vessels thereby preventing
bleeding, is removed. The membrane under the prepuce is excised and hemostasis

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 established. The cut edges are sutured with interrupted catgut and a gauze strip soaked in
TBC applied. The dressing is removed after 5 days.
Manage the circumcised penis as follows:
• Keeping the area clean to avoid secondary infection
• Put dry and clean napkins on the baby
• Remove dressing after 5 days
List of advantages of male circumcision as:
• It satisfies the social and religious obligations
• It serves as a treatment to some medical problems e.g Phimosis, Paraphimosis e.t.c
 It is hygienic
 Bleeding
 Infection
Female circumcision is still practiced in some communities. This should be strongly discourage,
Complications that can result from it are:
(1) Vaginal stenosis
(2) Severe perineal tears with hemorrhage that can result since the introitus is unable to stretch
and relax because of healing of the circumcision by fibrosis.

INTRAVENOUS THERAPY
Intravenous therapy is define as the introduction of fluid or drugs through the veins using a
sterilized needle or canula into the systemic circulation.
Intravenous fluid is define as solutions containing some electrolytes inform of glucose, fluid
electrolytes, calories which are usually introduced into the systemic circulation through the vein
using sterilized needle or canula for correcting and maintaining fluid and electrolyte imbalance.
Types of intravenous fluids:
 Isotonic normal saline
 1/5 normal saline in 4.3 % glucose
 1/2 normal saline in 2.7 % glucose
 5% dextrose
 Sodium lactate (1/6 molar)
 Ringer's lactate (Hartman's solution)
 Darrow's solution
The indications for intravenous therapy are as follows:
To correct fluid and electrolyte loss as in:
 Diarrhea
 Vomiting
 Dehydration
 Shock
 Intestinal obstruction
Dehydration is defined as loss of water and electrolytes, especially sodium. Total body of adult
male is about 60% of the (12 lit.) body weight and that of the female about 50 % (38-40 lit.) in
infants the total body water varies between (about- 70 lit) 75 % - 80 % of the body weight. The
average West African of 70 kg must loss 2.5 litres or fluid to show signs of dehydration.

Clinical features of dehydration include:

 Dry, inelastic skin with loss of turgor

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  Dry mouth
 Sunken eyes in severe cases
 With fluid loss of about 3.5 litres, shock with hypotension supervenes.
Dehydration in infants and children
Dehydration develops more quickly and has more serious effects in infants and children.
Dehydration may be mild, moderate or severe depending on the weight loss resulting from the
fluid deficit.
(1) Mild Dehydration: - Is when 21/2 % to 5 % of the body weight is lost as fluid. The child is
irritable, the tongue is dry, but the skin turgor is not altered.
(B) Moderate Dehydration: - When 5% - 10% weight is lost, the tongue is dry, the skin is
inelastic and the eyes and fontanelle are sunken, the urine is scanty
(C) Severe Dehydration (10 % - 15 % weight lost) in addition to the signs of moderate
dehydration, the child is unable to raise his head. The abdomen is scaphoid and the feet and
hands cold. The urine is very concentrated and the output very low. (Oligo Urier)
The treatment of dehydration in both infants and adults is replacement of fluids and electrolytes
by oral rehydration therapy or intravenous therapy
Set a tray containing the following:
 Intravenous fluid
 Giving set
 Sterile needle or canula
 Gallipot containing cotton swabs soaked in antiseptic
 Kidney dish for collecting used swabs
 Plaster and a pair of scissors
 Torniquet
Then
(1) With the patient lying down, inform patient about the procedure
(2) Wash hands
(3) Select appropriate site, prepare the infusion and hang on the drip stand.
(4) Tie a torniquct round the selected limb
(5) Clean properly will antiseptic and allow dry.
(6) Insert the needle or canula
(7) Hold with plaster
(8) Regulate the drip to the appropriate rate of flow giving a detailed written instruction as to the
rate of now and number of litres to be infused.
(9) Make patient comfortable and monitor closely. .

Complications
(1) Thrombophlebitis: May result from irritation of the vein. The affected vein is painful, tender
and thickened. It subsides with rest. Thrombophlebitis is prevented with changing the drip set
and the vein used for infusion every 48 hours.
(2) Local sepsis: It is often due to non-observance of the drip
(3) Septicemia: It results from contamination of the infusion solution or drip set.
(4) Overloading the circulation
(5) Air embolism.

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BLOOD TRANSFUSION
Define blood transfusion - The intravenous replacement of lost or destroyed blood compatible
human blood.
Indication for blood transfusion
 To restore blood volume in cases of sudden blood loss of moderate severity e g
hemorrhage
 To correct deficits in oxygen-carrying capacity of the blood to acute or chronic anaemia
of whatever cause. A unit of blood raises the hemoglobin by I gm/dl in adults.
 To correct deficiencies in the clothing factors or platelets. This approach is no longer
practiced in areas where fresh frozen plasma and specific factor concentrates are
produced.
 During major operative procedures where certain amount of blood loss is inevitable e.g
cardiovascular and orthopedic surgery.
 To provide red cells not susceptible to specific antibody destruction as in hemolytic
disease of neonates.
 Following severe burns where despite initial fluid and protein replacement, there may be
associated hemolysis.
Individuals fit for blood donation
 Donors who should be between 18-40 years better below20-30 years over 46 kg in weight
should be
 Fit Hemoglobin or over 12.5 gm/d1 in males and 12 gm/dl in females
 Free of history or clinical evidence and not carries of the following: viral liepatitis,
syphilis, Aids or trypanosomiasis. Blood is collected into a sterile commercially prepared
plastic bag will needle, and plastic tubes attached in a complete closed sterile unit.
Complications of blood transfusion:
Complications can be grouped into immediate and delayed reactions.
Immediate reactions
 Simple febrile reactions
 Allergic reactions
 Hemolytic reactions
 Bacterial contamination
 Circulatory over load
 Cardiac arrest Air embolism
Delayed reaction
 Thrombophlebitis
 Delayed hemolytic reaction
 Post transfusion Thrombocytopaenic purpura
 Transmission of diseases such as Viral hepatitis, malaria, syphilis and trypanosomiasis
The transfusion must be stopped immediately.

INCISION AND DRAINAGE

Abscess is define as localised collection of pus formed as a reaction to pyogenic organisms; it
may be chronic or acute cause by pathogenic organisms such as staphylococci.
Abscess formation

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In healthy individuals, local infection usually resolves spontaneously or under appropriate ant-
biotic regime. However one tissue destruction occurs, decomposition is inevitable because the
micro-organisms in the dead tissue are no longer accessible to systematic anti-microbial agents
Examples of abscess peculiar to skin
 pustules
 Furuncles
 Carbuncles
Indication for incision and drainage:
 When the abscess is ripe and fluctuant
 Not resolving with antibiotic therapy
 Causing significant pain.
Instruments required for incision and drainage:
 A standard sterile dressing pack
 Sterile towels and clips
 Lotions such as savlon and hibitane in spirit, for skin cleaning
 Syringes and needles for above
 Ethyl chloride spray, if used
 Receiver
 Bard packer handle and blade
 Sinus forceps scissors
 Probe
 Curette
 Fine curved mosquito forceps
 Spencer wells artery forceps
 Swabs stick for taking sample for microscopy, culture and sensitivity

FRACTURES
Fracture is define as a structural break in the normal continuity of bone. Trauma is the
commonest cause of fractures and can result from
(1) Road traffic accidents
(2) Industrial accidents
(3) Occupational hazards
(4) Falls: - especially in children and elderly people
(5) Pathology or disease of the bones: - If the bones are not healthy then they ac liable to break
with a minimum amount of violence eg osteomyelitis, rickets, osteoporosis, cancer of the bone
e.t.c
Fractures can broadly be classified into:
(1) Simple or closed fracture
(2) Compound or open fracture
Simple or closed fracture: - Is when the fracture site does not communicate with the surface
through a wound hence there is no risk of infection

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Compound or open fracture is when the fracture site communicates with the outside through a
laceration. Bacteria can therefore reach the site and cause infection

CLOSED

OPEN

COMPLIVATED

GREENSTICK

In the case of fracture of the shaft of a long bone, there are five possible types of displacement.
There are
(I) Shift: This refer to loss of alignment of the cortices of the Indian fragments.
(2) Angulation: Refers to loss of the normal longitudinal axis of the shall
(3) Shortening: Usually occurs due to overlap of the bone fragment
(4) Twist: Refers to rotation of the distal fragment around the long axis of the bone, cither
external or internal,
(5) Distraction: This is when the two bone fragments are in alignment with an appreciable gap
between them, usually produced by over vigorous fraction during treatment.
Union: This refers to the healing of a fracture healing by the formation of bone at the fractured
site uniting the fracture fragments. The time taken for a fracture to unite depends not only on the
age of the patient but also on the bone involved and the type of fracture,
In general:
(1) Lower limb fractures taken twice as long to unite an upper limb fractures
(2) Fractures in adults take twice as long to unite as fractures in children
(3) Transverse fracture take longer to unite than oblique or spiral fractures.
(4) Compound and comminuted fractures are particularly slow to unite.
(5) No fracture unites in less than 3 weeks.
Non-union: Is when the healing process stops while the fracture was not united. Non-union
results from interposition of soft tissue and inadequate immobilization or delayed union,
 Initial Injury: Compound fracture are more likely to develop delayed union. This is due to
the associated tissue injury which also produces impairment of blood supply of the bone
fragments.
 Infection of the fracture hematoma usually loads to non-union and if it occurs, it is a
disaster. Healing fails because the cellular elements which are required for the production
of bone at the fracture site are delivered to the production of pus,
 Interposition of soft tissue: Between the fracture fragments may so separate them that it is
physically impossible for them to unite.

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  A poor blood supply to the fracture site interferes with healing since the invasion of the
haematoma by blood vessels is slow or absent since the invasion of the hacmatoma by
blood vessels is slow or absent
 Inadequate immobilization leading to excessive movement at the fracture site during
healing phase may produces delayed union because the callus bridging the fracture site is
constantly refactored by movement occurring in the healing tissues.
 Systemic disease,
 Pathological fractures
 Distraction of fracture fragment

MANAGEMENT OF CLOSED FRACTURES OF LONG BONES

Management of a fracture involves the taking of the good history, physical, examination,
investigation and treatment of the fracture itself taking into account the general condition of the
patient as a whole.
There is usually a history of trauma which might be due lo road traffic accident, a fail industrial
accident e.t.c in pathological fracture
There is a history of minimal trauma. The patient complains of pain and swelling at the fracture
site and sometimes inability to use the affected limb.
The area of fracture is
 Swollen and tender
 There is deformity if the fracture ends are displaced
 Abnormal movement might be possible at the tincture site giving a sensation called
crepitus when the bone ends are moved against each other.

Radiography
When a fracture is suspected on clinical grounds, the on clinical ground, the diagnosis is
confirmed by taking X-rays. Anterior-posterior and lateral were taken of the whole bone
including the joint above and below the fracture site so that the full extent of the injury can be
seen.
Treatment of a fracture can be considered under two headings:
1. General treatment of patient as a whole
2. Local treatment of the fracture itselfb
General Treatment
Pain: All Resumes are painful and it is important that pain is relieved immediately. This is
achieved by local splinting and analgesics, according to standing orders
Blood Loss: All fractures are associated with some blood loss. This may be negligible but in
fractures of the major long bones eg. Shalt of the femur up to 2 liters of blood can be lost.
Associated injuries: Associated injuries e.g injuries to the blood vessels or nerves in a limb
require expert attention. In case of associated soft tissue injury, which is effective against
spectrum antibiotic which is effective agaimst staphylococcus Aureus should be administered
Local Treatment: The long bones of the body are the bones of the upper and lower limbs. These
are upper limbs Humerus Radius, Ulna and metacarpal bones.
Lower limbs Femur, Tibia, Fibula and Metatarsal bones.
When fractures of those bones are suspected, apply splints and refer after managing according to
standing orders.

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 HOW TO MAKR ARM SLING

IMMOBILIZED LOWER LIMB

CHOKING - TREATMENT

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1. Encourage coughing
2. Up to 5 back Slaps
3. Check Mouth
4. Up to 5 abdominal thrusts
5. Check Mouth
>Repeat sequence – Call for help

HEART ATTACK RECOGNITION

1. Persistent Crushing chest pain
2. Pain can radiate to jaw, neck and down the arm
3. Not relieved by rest
4. Sudden Collapse

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TREATMENT
1. Position
2. Call for help
3.
4. Give 300mg Aspirin tab to chew
5. Monitor and reassure
6. Ready to commence CPR
7. Get AED if available

NASO - GASTRIC TUBE

A naso-gastric tube is a hollow be made of plastic, inserted through the nose into the gastro-
intestinal tract to aspirate or fluids.
Indications for the use of naso-gastric tubes
Feeding
 Naso-gastric tube is inserted for feeding premature babies, semi-unconscious patients.

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  Naso-gastric tubes are also used pre and post operatively to empty the contents of the
stomach.
Procedure for inserting a naso-gastric tube:
Set a tray containing:
1. 2 sterile kidney dishes
2. 2 sterile gallipots
3. Swabs
4. Syringes
5. Sterile waTcr in a feeder or cup
6. Lubricant
7. New sterile Naso-gastric tube
8. Plaster for strapping
9. A Vomit bowl
PROCEDURES
 Screen the patient to ensure privacy
 Explain the procedure to the patient
 Make patient as convertible as possible, sitting upright with adequate support from
pillows.
 A large towel is draped round his shoulders to protect the clothes
 Lubricate the tube will a lubricant e.g Liquid paraffin
 Then introduce the Naso-gastric tube through the nose with very great care
 The vomit bowl is very much at hand in case patient starts vomiting.
 The patient is asked to swallow repeatedly, and if he feels he is going to vomit, he should
stop swallowing, open his mouth and take deep breaths.
 Care is taken to make sure the tube does not coil up in the pharynx, which is almost
certain to happen if the CHO pushes it too fast. The tube should be passed so that the
nostril is just short of the second ring, at about 50cm.
 Then test if it is in the stomach aspirating the stomach contents. If the tube is in the
stomach, the aspirate will turn blue litmus paper red. Then the end of the strapped to the
temple. A 20-ml syringe, without the baby or patient

Complications of inserting of naso gastric of tube:

 Insertion of tube into the lung may cause aspiration pneumonia, if feeding introduced
without confirming that the tube is in the G.I.T.
 Injury to the gastrointestinal mucosa causing pain and hemorrhage when a lot of force is
used.

URINARY CATHETERIZATION
Urinary catheterization as the process of inserting a urethral catheter into the urinary bladder to
evacuate urine.
Indication for urinary catheterization:
(1) Acute retention of urine
(2) For collection of urine specimen for laboratory analysis.
(3) During labour

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(4) Unconscious patients
(5) Urethral strictures
Foley’s catheter: This is the most commonly used of all catheters. It is a straight rubber or
polythene catheter with a thin rubber cut or balloon near the tip behind the eye. This balloon after
introduction of the catheter into the bladder, is distended with sterile water injected through a
thin tube incorporated in the wall of the catheter,
The process of Catheterization:
(a) Male Catheterisation
Set a tray containing the following:
1. 3 Sterile kidney dishes
a. One for steilele catheter,
b. Another for dressing forceps.
c. Another for collection of used swabs
2. 3 Sterile gallipots
a. One for lubricants
b. One for sterile water
c. One for cleaning agent
3. Sterile bowl: Containing sterile gauze and cotton wool
4. Specimen bottle or container for collecting urine specimen
5. Pair of sterile gloves
Procedure
1. Provide privacy to the patient by screening the patient
2. Inform patient about the procedure
3. Carry tray to the patient's bedside
4. Wash hand and wear gloves
5. Then open the bowls
6. Position patient for the procedure
7. Hold penis in a gauze swab
8. Cleanse glans with the cetrimide solution
9. The sterile kidney dish containing the catheter is placed across the legs.
10. The catheter is lubricated then introduced with a Nash catheter forceps
11. The catheter should slide easily through the urethra and the urine should flow when there is
still approximately 10 - 15 cm of catheter outside
(b) Female Catheterisation
Set tray above (like for male Catheterisation)
1. Provide privacy
2. Inform patient about the procedure
3. Carry tray to the patients bed
4. Position patient for the procedure
5. Wash hands, the wear gloves
6. Open up bowls and kidney dishes
7. Clean vulva with cetrimide solution

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 8. Place sterile gauze swab on each labium to prevent the finger slipping and to make quite
certain that the catheter is not contaminated during insertion
9. The catheter in the sterile kidney dish is beneath the vulva. The catheter is lubricated and
then inserted with catheter or dressing Porceps.il a Foley's catheter is used, it is inflated
with sterile water 5mls or more depending on the size and purpose

ACUTE ABDOMEN
The acute abdomen is an abdominal condition of sudden onset that may require immediate
operative treatment.
There are many conditions that give rise to acute abdomen. They can be broadly grouped into
categories:
(1) Inflammatory Conditions: - examples arc:
(a) Acute appendicitis
(b) Acute salpingilis
(c) Cholecystitis
(2) Perforation of a hollow viscera e.g
(a) Typhoid perforation of the ileum
(b) Perforation of peptic ulcer
(c) Traumatic perforation
(d) Perforation of amocbic colitis
(3) Intestinal Obstruction e.g
(a) Strangulated hernia
(b) Intussusception
(c) Tumours
(3) Hemorrhage e.g
(a) Rupture ectopic pregnancy
(b) Traumatic rupture of viscera especially the spleen
(c) Ruptured aortic aneurysm.
(4) Medical Conditions that may cause abdominal pain are:
(a) Gastro enteritis
(b) Dysentery
(c) Sickle cell disease
(d) Urinary tract infection
(e) Malaria
(f) Pneumonia
To determine the cause of an acute abdominal condition, it is necessary to bet an accurate history
from the patient, examine the patient thoroughly and most important to have a good knowledge
of the clinical features of the various acute abdominal conditions.
(1) Inflammatory Group
(a) The pain usually starts gradually, is constant and worse on movement
(b) The patient may have nausea and vomit occasionally.
(c) There is loss of appetite
(d) Tenderness, rebound tenderness guarding or rigidity arc elicited in the areas which the
inflamed viscous is situated. For example in acute appendicitis, the above signs are in the right
iliac fossa.

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(c) If the peritoneum is involved, the inflammation becomes generalized and the entire
abdominal will becomes tender and the symptoms worse.
(2) Perforations
(a) The pain starts suddenly
(b) The patient might have nausea and vomit
(c) The entire abdominal wall is tender and may be as rigid as a boards. Bowel sounds arc absent
on auscultation and the tenderness is worse at the site of origin of the perforation.
(d)Typhoid Perforation
In typhoid perforation there may be a history of diarrhea, fever and headache before the onset of
serve abdominal pain.
(e) Peptic Ulcer Perforation
In peptic ulcer performance, there may be a history of epigastric pain radiating to the back.
(f) Traumatic Perforation
In Traumatic Perforation there is a history of trauma.
(3) Intestinal obstruction:
The patient will usually complain of:
(a) Colicky abdominal pain
(b) Vomiting and/or distension and
(c) Absolute constipation.
When the patient is examined:
(i) There may be a tender irreducible swelling in a hernial orifice e.g. an inguinal or
femoral hernia.
(ii) Waves of peristalsis might be visible on the abdomen.
(iii) Bowel sounds arc absent on auscultation of the abdomen
(4) Hemorrhage:
The signs are:
a. Pallor
b. Sweating
c. Rising pulse rate
d. Falling blood pressure
e. The abdomen may be distended with blood
f. The abdomen is tender
In rupture ectopic pregnancy there is a history of missed period and slight vaginal bleeding. A
history of trauma with above signs of hemorrhage suggests a ruptured viscous: There may be
abrasions on the abdomen.
(5) Medical Conditions that may cause abdominal pain
(a). Pneumonia
This is important especially in children
i. Respiration is rapid, and the temperature is high
(ii) Clinical signs are present in the chest
(iii) Pain is referred to the right iliac fossa but the abdomen is soft
(iv) X-ray of the chest will confirm the diagnosis.
(b) Malaria
(i) Pain may be referred to the right iliac fossa
(ii) The temperature is high with associated headache and achc in the muscles
(iii)The abdomen is soft

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(iv) Malaria parasites are seen in the blood film
(c). Dysentery.
(i) Patient has central and lower abdominal colicky pain associated with passage of watery,
mucous, blood stained stools. In between attacks there is no pain.
(ii) Abdomen is soft.

(d) Gastroenteritis
(i) Vomiting and frequent stooling occur
(ii) The abdomen is soft
(iii) There is a history of dietary or alcoholic indiscretion
(e) Urinary tract infection
(i) There is frequency of urination
(ii) There may be a rise in temperature
(iii) Blood and pus cells are present in the urine.
Urinalysis should be done and mid-stream urine collected for microscopy, culture and sensitivity
(f) Sickle Cell Disease
(i) Patient is anemic
(ii) Joint aches are present
(iii)Splenomegaly and hepatomegaly may be present.
(iv) The abdomen is soft but may sometimes be tender with guarding
(v) Electrophonic is positive
Treatment will depend on the cause. Generally, the patients is:
(1) Resuscitated by intravenous fluid therapy and nasogastric aspiration.
(2) Half-hourly with frequent clinical re-assessment are carried out while analgesics are
withheld.
As soon as the diagnosis becomes certain appropriate measure should be taken.

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