Common injuries in general practice
Executive Editor, InnovAiT
E-mail: chantal.simon{at}oxfordjournals.org
 |
Abstract |
|---|
 TOP Abstract Common injuries and the...WoundsNail injuriesForeign bodiesInsect and fish stingsMusculoskeletal injuriesFracture complicationsHead injuryEye traumaScalds and burnsReferences |
|---|
Although most people who injure themselves receive treatment at Accident & Emergency (A&E) or a Minor Injuries Unit, presentation of minor injuries to general practice, either to the GP directly or via the practice nurse, is a common occurrence. There are several reasons for this. Often patients have to wait a long time in A&E and presentation to the GP may save them time; it may be more convenient to go to the GP surgery rather than the A&E department if the A&E department is a long way away or the patient has difficulties with transport. Some patients may just prefer to see a doctor that they know and trust. In addition, many A&E departments give advice that injuries more than 2 days old should be presented to the GP rather than an A&E department. It is essential that GPs have a thorough knowledge of how to best manage these patients.
In some areas, specialized minor injuries services are provided by GPs as a National Enhanced Service, either in the GP surgery or in community hospitals. GPs providing the service must be appropriately trained. The practice receives an annual fee for providing the service plus a fee per patient treated.
GPs in training should recognize how geographical distance influences the treatment of trauma in a primary care setting. Curriculum statement 15.9: Rheumatology and conditions of the musculoskeletal system (including trauma) requires GPs to be able to intervene urgently when patients present with trauma in a primary care setting. It lists common injuries as important conditions and requires GPs to be able to assess minor injuries such as cuts, bruises and wounds in primary care and understand the indications for referral for X-ray, including the Ottawa rules. It also requires GPs to be familiar with the initial management of patients who have been burnt. Suturing and application of simple dressings are skills that should be acquired in the course of GP training. Curriculum statement 15.4: ENT and facial problems requires GPs to be able to recognize the symptoms of a foreign body in the ear or nose and treat the patient appropriately. In addition, GPs in training must be able to manage nasal fracture and understand the need for manipulation under anaesthetic within 2 weeks of fracture for optimum result and be able to manage septal haematoma and haematoma of the pinna (haematoma auris). Curriculum statement 15.5: Eye problems requires GPs to be able to recognize and institute primary management of ophthalmic emergencies and refer appropriately:
|
|
Wounds |
|---|
|
TOPAbstractCommon injuries and the...WoundsNail injuriesForeign bodiesInsect and fish stingsMusculoskeletal injuriesFracture complicationsHead injuryEye traumaScalds and burnsReferences |
|---|
Most patients with significant lacerations present directly to Accident & Emergency (A&E). If a patient presents to general practice, perform immediate care—elevate the bleeding limb and apply pressure to arrest bleeding. Advise nil by mouth and transfer the patient to A&E.
Minor lacerations
Minor lacerations can often be managed in primary care. First, ensure that there is no foreign body in the wound. If in doubt, refer for an X-ray and/or surgical exploration. This is especially important if the injury was with glass. Wash the wound and clean away debris and any necrotic material. Check that there is no damage to underlying nerves, tendons, bone or blood supply before dressing or closing the wound. Aim to oppose the skin edges without tension to allow healing. Do not attempt to close a wound if you are not confident that you can achieve an adequate result. Always refer cuts through the lip margin to A&E and consider referral to A&E for any facial wounds or if it is a child that is wounded. In all cases, check the patient's tetanus status (Fig. 1). In assault cases, take particular care to document all injuries carefully, for example, with photographs, drawings and measurements of wounds. Always consider non-accidental injury (NAI) in children.
|
There are several options for closing wounds:
- Skin closure strips (Steristrips)—can be used for small cuts in non-hairy skin not under tension. For larger wounds, steristrips can be used in addition to sutures.
- Skin ‘glue’ (e.g. Histoacryl)—this is quick, it takes just 30 seconds to set, and can be used on hairy skin such as the scalp
- Suturing— should not be undertaken unless you have received appropriate training. Infiltrate the wound edges with 1% lidocaine (maximum dose—adult 200 mg; child 3 mg/kg). Addition of adrenaline (epinephrine) can help haemostasis but must not be used on digits as necrosis can occur. Take care to oppose the edges of the wound accurately. Use an appropriate suture for the task. For example, 5-0 monofilament nylon, removed after 5 days, is an appropriate choice for an adult face or 3-0 monofilament nylon, removed after 10–12 days, is appropriate for the limbs or trunk.
Pretibial lacerations
The shin has poor blood supply especially in the elderly. Flap wounds are common, may heal poorly or even break down to form ulcers. Wash the wound and carefully realign the flap. Secure the flap with steristrips without tension and bandage. Advise the patient to elevate the leg. Review regularly to check that the wound is healing.
Animal bites
Around 200 000 people are bitten by dogs each year in the UK. All animal bites (including human bites) are contaminated and wound infection is common. Clean the wound carefully with soap and water. Check the patient's tetanus status (Fig. 1). Do not suture the wound unless it is cosmetically essential and there is minimal tissue damage—refer to A&E if you are in doubt. Give prophylaxis against infection, for example, with co-amoxiclav 250/125 tds or flucloxacillin (or erythromycin) 250–500 mg qds and metronidazole 400 mg tds for 5–7 days.
If the patient has been bitten by a human, also consider the risk of Hepatitis B and HIV infection. If HIV prophylaxis is indicated, it needs to be started immediately, so refer to A&E for local policy implementation.
Punch injuries over the knuckles are often associated with tooth lacerations and involvement of the underlying metacarpophalangeal joint. In all cases where this is suspected, refer to A&E.
Snake bites
The adder is the only poisonous snake in the UK. Bites are only rarely lethal. Attempt to identify the snake species and refer the patient urgently to hospital. Do not apply a tourniquet or try cutting or sucking the wound.
|
Nail injuries |
|---|
|
TOPAbstractCommon injuries and the...WoundsNail injuriesForeign bodiesInsect and fish stingsMusculoskeletal injuriesFracture complicationsHead injuryEye traumaScalds and burnsReferences |
|---|
Two nail injuries are commonly seen in primary care—avulsion and subungual haematoma. Protect the nail bed of an avulsed nail with soft paraffin and gauze, check the patient's tetanus status (Fig. 1) and give antibiotic prophylaxis (e.g. with flucloxacillin 250 mg qds for 5 days). Partially avulsed nails need removing under ring block to exclude an underlying nail bed injury—replace the avulsed nail in its usual position to act as a splint to the nail matrix. Do not attempt this unless you have had the training to do so.
A blow to the finger can cause bleeding under the nail. This is very painful due to pressure build-up. Relieve the pressure by trephining a hole through the nail using a 19-gauge needle. No force is required. Just twist the needle as it rests vertically on the nail. Alternatively, use a heated point (such as a paper clip or cautery instrument) to burn a hole through the nail. This can be of benefit for up to 2 days after the injury.
|
Foreign bodies |
|---|
|
TOPAbstractCommon injuries and the...WoundsNail injuriesForeign bodiesInsect and fish stingsMusculoskeletal injuriesFracture complicationsHead injuryEye traumaScalds and burnsReferences |
|---|
Foreign bodies in the skin are common. The most common culprits are splinters which can easily be removed with a pair of tweezers and/or needle or gravel in a graze that can be washed out or picked out with a pair of tweezers. If a patient presents after being shot with an air gun pellet, always refer for X-ray. Air gun pellets can be difficult to remove and may be left in place if they are not in a harmful position. If the pellet is in a joint, always refer for surgical removal.
Another common injury occurs when a patient gets a fishhook stuck through the skin. Infiltrate the area with lidocaine. Push the hook forward through the skin until the barb is exposed. Cut the barb off and then ease the hook back through the skin the same way that it entered.
Foreign body ingestion
Patients may also present with foreign body ingestion. Most coins or blunt objects will pass through the gut without any problems. If asymptomatic, they can be left to take their course. Advise patients (or parents) to check the stools to ensure the foreign body is passed. If the patient is symptomatic, or has ingested a battery or sharp object, refer for X-ray and consideration for endoscopic removal. If there is any indication of aspiration refer urgently.
Foreign bodies in the ear or nose
This is most common in children. Usually, there is a history of the child putting the object in the ear or nostril, but occasionally children may present with unilateral offensive discharge. Do not try to remove a foreign body yourself unless the object is very superficial and the child cooperative. You might push the object further in and cause trauma. Removal under general anaesthetic may be needed. Insects in ears can be drowned in oil and syringed out.
Removal of a ring from a swollen finger
Rings may become stuck on swollen fingers. This is painful and eventually may damage the finger. Try slipping the ring off by running cold water over the finger to reduce swelling and then applying liberal amounts of a lubricant such as soap or emollient cream. If this is unsuccessful, try winding cotton tape around the finger advancing towards the ring. Then thread the tape through the ring and pull on this end to unwind the tape. This levers the ring over the proximal interphalangeal joint where it tends to get stuck. If neither of these tactics works, use a ring cutter.
|
Insect and fish stings |
|---|
|
TOPAbstractCommon injuries and the...WoundsNail injuriesForeign bodiesInsect and fish stingsMusculoskeletal injuriesFracture complicationsHead injuryEye traumaScalds and burnsReferences |
|---|
Insect bites and stings are very common. The effect of the sting on the individual depends on the insect involved and the individual's response to the sting and ranges from blisters through papules to urticarial wheals. Immediately after the sting, remove any sting present in the wound. Often, no further treatment is needed. If a severe local reaction occurs, then apply an ice pack and give an oral antihistamine such as chlorphenamine 4 mg stat. Continue chlorphenamine 4–6 hourly as needed. Secondary infection is common. If suspected, prescribe an antibiotic such as flucloxacillin 250 mg qds. Rarely, anaphylaxis may occur in response to an insect sting. Treat according to the Resuscitation Council's anaphylaxis guidelines (Fig. 2) and transfer to hospital as a blue light emergency.
|
In many areas of the UK, ticks are common (Fig. 3). These are best removed with a commercial tick remover. If a tick remover is not available, an alternative is to place a large blob of petroleum jelly (Vaseline) over the tick. It suffocates over a few hours and can then be removed easily with a pair of tweezers.
|
Weaver fish are common on sandy beaches in the UK. The fish lurks under the sand so is usually trodden upon. Patients present with severe pain in the foot. Immerse the affected area immediately in uncomfortably hot (but not scalding) water. Give analgesia. The pain resolves after 2–3 days. Jellyfish stings can also occur in the UK. Remove the patient from the sea as soon as possible and scrape or wash adherent tentacles off. Alcoholic solutions including suntan lotions should not be applied because they may cause further discharge of stinging hairs. Ice packs reduce pain and a slurry of baking soda (sodium bicarbonate), but not vinegar, may be useful for treating stings from UK species.
|
Musculoskeletal injuries |
|---|
|
TOPAbstractCommon injuries and the...WoundsNail injuriesForeign bodiesInsect and fish stingsMusculoskeletal injuriesFracture complicationsHead injuryEye traumaScalds and burnsReferences |
|---|
In all cases, take a history and examine the patient to confirm the diagnosis and exclude fracture or dislocation. Common fractures seen in primary care are summarized in Table 1. Fractures or dislocations are characterized by pain at the affected site, worse on movement and decreased function. On examination, there may be bruising, deformity, local tenderness, impaired function, crepitus and/or abnormal mobility. If a fracture or dislocation is suspected, immobilize the affected part and give analgesia. If available and the patient is shocked, start an IV infusion. Refer to A&E for assessment, X-ray and treatment. For ankle and foot injuries, the Ottawa rules may help you to decide whether an X-ray is necessary (Box 1).
|
| Box 1. Ottawa rules for ankle or foot injury Twisting of the ankle resulting in pain and swelling is a very common injury. Foot injuries are also common. It can be difficult to distinguish between a sprain and a fracture. The Ottawa rules reduce the need for X-ray by a quarter: Ankle injury Refer for an ankle X-ray if there is pain in the malleolar area and
Foot injury Refer for a foot X-ray if there is pain in the midfoot and
Otherwise diagnose a sprain
|
Most musculoskeletal injuries seen in primary care are muscular injuries (haematomas or strains) or ligament injuries (sprains). If a ligament injury is suspected and there is abnormal movement of the joint, then refer for orthopaedic review, otherwise treat with a RICE regime:
- Rest—Relative rest of the affected part while continuing other activities to maintain overall fitness
- Ice and analgesia—Use immediately and in the first 2–3 days after the injury. Wrap ice in a towel and apply it for a maximum of 10 minutes at a time to prevent acute cold injury. Suitable analgesia is paracetamol 1 g qds and/or ibuprofen 400 mg tds/qds.
- Compression—Taping or strapping can be used to reduce swelling and provide support
- Elevation—This reduces local swelling and dependent oedema enabling quicker recovery
If the injury is not settling in 6 weeks, refer to physiotherapy—sooner if the patient is an athlete or the injury is preventing work.
Whiplash
Whiplash is neck pain due to stretching or tearing of cervical muscles and ligaments due to sudden extension of neck—often as a result of a road accident. Pain and reduced neck mobility typically starts several hours or days after the injury. Pain may radiate to the shoulders, arms and head. Examine the patient carefully to exclude bony tenderness requiring X-ray. Treat with ice, analgesia and early mobilization. A soft collar may help initially but avoid long-term use. Recovery is often slow and 40% of patients suffer long-lasting symptoms. As a general rule of thumb, the quicker the symptoms develop, the longer they will take to disappear. Early physiotherapy, if available, can improve recovery rate. Psychological problems and medico-legal issues can affect progress.
Shoulder dislocation
Shoulder dislocation is usually due to a fall onto an arm or shoulder. Anterior dislocation is most common. On examination, shoulder contour is lost (flattening of deltoid) and the head of the humerus is seen as an anterior bulge. The axillary nerve may be damaged resulting in absent sensation on a patch below the shoulder. If suspected, refer to A&E for X-ray and reduction. If the patient has recurrent shoulder dislocations, refer to orthopaedics for specialist physiotherapy and consideration for surgery.
Pulled elbow
Pulled elbow is common in children less than 5 years of age. Traction injury to the elbow causes subluxation of radial head. This often occurs when the child is pulled up suddenly by the hand. The child will not use the arm but there are usually no other clinical signs. The condition affects boys more often than girls and the left arm is most likely to be affected. X-rays are unhelpful. Apply anterior pressure with the thumb on the radial head while supinating and extending the forearm. Immediate recovery is seen after reduction.
Mallet finger
The fingertip droops due to avulsion of the extensor tendon attachment to the terminal phalanx (Fig. 4). If suspected, refer for X-ray. Management is with a plastic splint which holds the terminal phalanx in extension and is worn continuously for 6 weeks to help union. Arthrodesis may be needed if healing does not occur.
|
Gamekeeper thumb
Forced thumb abduction causes rupture of the ulnar collateral ligament. This can occur on wringing pheasants’ necks—hence the name—or, more commonly, acutely by catching the thumb in the matting on a dry ski slope. The thumb is very painful and pincer grip weak. Refer to A&E or orthopaedics as open surgical repair is the most effective treatment.
|
Fracture complications |
|---|
|
TOPAbstractCommon injuries and the...WoundsNail injuriesForeign bodiesInsect and fish stingsMusculoskeletal injuriesFracture complicationsHead injuryEye traumaScalds and burnsReferences |
|---|
Fracture complications often occur after a patient has been discharged from hospital and may present as a primary care emergency. Patients should not have persistent pain. If they do, think of compartment syndrome. Refer back to the fracture clinic or A&E if:
- The patient has persistent pain
- There is limb swelling that is not settling
- There is an offensive odour or discharge
- Cast edges are abrading the skin or if the cast has deteriorated in structural strength, for example from getting wet
Compartment syndrome
Crush injury, fracture, prolonged immobility or tight splints, dressings or casts can result in increased pressure within muscle compartments and ultimately lead to vascular occlusion. Hypoxia and necrosis cause further increase in pressure. Symptoms and signs include swelling, severe pain that is increased on passive stretching of the muscles, distal numbness, redness, mottling and blisters. Pulses may still be present distally. If suspected, loosen any restricting bandage or cast. Refer as an emergency for orthopaedic assessment. A fasciotomy may be necessary to relieve the pressure.
|
Head injury |
|---|
|
TOPAbstractCommon injuries and the...WoundsNail injuriesForeign bodiesInsect and fish stingsMusculoskeletal injuriesFracture complicationsHead injuryEye traumaScalds and burnsReferences |
|---|
If a patient has sustained a severe head injury, perform basic life support, protect the cervical spine and transfer to A&E by ambulance. For patients who have sustained less severe head injuries, if possible take a history from a witness as well as the patient. Ask about circumstances of injury, loss of consciousness (LOC), seizures, current symptoms and behaviour. Check the scalp and head for injury and perform a brief neurological examination (including fundi). Look for other injuries. Accompanying neck injuries are common.
Refer to A&E if:
- Glasgow Coma Scale is less than 15 at any time since the injury (Table 2)
- Any LOC
- Focal neurological deficit since the injury—problems speaking, understanding, reading, writing, decreased sensation, loss of balance, weakness, visual changes, abnormal reflexes, problems walking, irritability or altered behaviour—especially in young children
- Any suspicion of skull fracture, penetrating head injury, blood or cerebrospinal fluid (CSF) in the nose or ear or CSF in a wound, serious scalp laceration or haematoma
- Amnesia for events before or after the injury
- Persistent headache
- Vomiting
- Seizure
- Any previous cranial neurosurgical interventions
- High-energy head injury (e.g. a pedestrian hit by a motor vehicle, a fall of greater than 1 m or more than 5 stairs)
- History of a bleeding or clotting disorder or on anticoagulant therapy
- Difficulty in assessing the patient (e.g. very young children, elderly, intoxicated or epileptic) or concern about diagnosis
- Suspicion of NAI
- Inadequate supervision at home
|
If there is a history of neck pain or neck injury, immobilize the neck and refer to A&E.
If examination is normal
Warn the patient (and carer) that he/she may suffer mild headaches, tiredness, dizziness, tinnitus, poor concentration and poor memory for the next few days. Advise rest and paracetamol (but not codeine-based analgesics) for the headache. Young children can be difficult to assess—sleepiness is common and not a worrying sign as long as the child is rousable. Give verbal and written head injury information regarding warning signs to trigger reconsultation. These are drowsiness, severe headache, persistent vomiting, visual disturbance and/or unusual behaviour.
Intracranial haemorrhage
Subdural haemorrhage occurs when there is bleeding from bridging veins between the cerebral cortex and venous sinuses, resulting in accumulation of blood between the dura and arachnoid. It may occur spontaneously or as a result of trauma, though the trauma may be trivial. Incidence increases with age, and the condition is more common in those prone to falls (for example heavy drinkers or epileptics) and patients on anticoagulant therapy. Presentation is often insidious and the history may go back weeks. Features include:
- Fluctuation of conscious level (35%) and/or sleepiness
- Physical and intellectual slowing and/or personality change
- Headache
- Unsteadiness on feet
- Slowly evolving stroke (e.g. hemiparesis)
- Other symptoms and signs of raised intracranial pressure—sixth nerve palsy, papilloedema, dropping pulse, rising blood pressure and/or pupil changes (constriction first then dilatation)
If suspected, admit as a medical emergency for further investigation. Evacuation of clot is possible even in very elderly patients and often results in full recovery.
Extradural haemorrhage occurs when blood accumulates between the dura and bone of the skull. It usually occurs after head injury and presents with deterioration of level of consciousness after a head injury that initially produced no LOC or after initial post-injury drowsiness has resolved. This ‘lucid’ interval may last anywhere from a few hours to a few days. Deterioration may be accompanied by worsening headache, vomiting, confusion and/or focal neurological signs. If suspected, admit as an emergency for further investigation. Early evacuation of clot carries excellent prognosis. Outlook is less good if there is coma preoperatively.
Injury to the face
Facial injuries are often due to road accidents or violent incidents. Always document the injuries carefully as your notes may be needed for legal proceedings. Look for other injuries such as airway problems, head injury or neck injury. Neurological assessment is required if the patient has had a head injury or LOC. Always look for associated fractures of the zygoma and maxillary bones (‘step’ deformity in the orbit, dental malocclusion, difficulty opening the jaw and diplopia) and refer urgently to the maxillofacial surgeons if present. Check the patient's tetanus status. Post-traumatic stress disorder is common after facial injury.
Nasal injuries
Septal haematoma may occur after nasal injury and causes nasal blockage. It presents as a bilateral soft bulging of the septum. Refer urgently to ENT for evacuation to prevent cartilage destruction.
Undisplaced nasal fractures can usually be allowed to heal without intervention. X-rays are unhelpful. Give adequate analgesia and advise that bruising may be extensive and the nose will feel blocked for 1–2 weeks. Assessment for permanent deformity can be difficult at the time of the injury due to soft tissue swelling, so reassess 7–10 days after injury. Refer any patient with significant deformity, or if the patient is unhappy with the appearance of the nose, to the ENT department for reduction under general anaesthetic. Ideally, reduction should take place within 1–2 weeks of the injury and a maximum of 3 weeks after fracture, so refer promptly. Deviation of the nasal septum may not be correctable at the time of manipulation and if symptomatic will need a later submucous resection.
Dislocated jaw
A dislocated jaw presents with pain and the mouth is stuck open. Refer for X-ray and reduction via maxillofacial surgeons or A&E.
Knocked out teeth
If there are no other injuries requiring attention, ask the patient to suck the tooth clean and reinsert the tooth into its socket or store it in milk. Advise the patient to go to the dentist as an emergency.
Haematoma of the pinna
Haematoma of the pinna usually occurs after trauma (e.g. playing rugby or boxing). The blood must be evacuated urgently either by aspiration with a large bore needle or surgically, to prevent necrosis of the cartilage and ‘cauliflower’ ear. Refer to ENT.
|
Eye trauma |
|---|
|
TOPAbstractCommon injuries and the...WoundsNail injuriesForeign bodiesInsect and fish stingsMusculoskeletal injuriesFracture complicationsHead injuryEye traumaScalds and burnsReferences |
|---|
Abrasions and foreign bodies
Both corneal abrasions (Fig. 5) and superficial foreign bodies in the eye (Fig. 6) cause discomfort, a ‘foreign body sensation’ and watering. Take a careful history to exclude high-speed particles, for example, from a strimmer, drill or lathe, that could cause penetrating injury. Examine the eye carefully for foreign bodies, including everting the eyelids. Use fluorescein stain with blue light illumination to detect abrasions.
|
|
If the foreign body is metal or a penetrating injury is suspected, then refer to eye casualty. A ‘rust ring’ may form around a metal foreign body if left for more than 12 hours. Superficial foreign bodies can be removed with a corner of clean card after instilling local anaesthetic (such as oxybuprocaine 0.4% drops). If that fails, you can try using the tip of a sterile green needle (bent if necessary)—but be careful. Refer to eye casualty if you are not confident. If there is no foreign body, or once the foreign body has been removed, treat with topical antibiotics such as chloramphenicol four times daily until healing is complete. Abrasions usually heal within 48 hours.
Blunt injury
Blunt injury to the eye is most commonly caused by fists and squash balls. The result may be anything from a ‘black eye’, through ‘blowout’ fracture of the orbit, to globe rupture. Globe rupture is usually obvious with a wound and severely reduced vision. More minor injuries include subconjunctival haemorrhage or corneal abrasion. Refer to eye casualty if:
- Visual acuity is affected or there is double vision
- There is a lacerated conjunctiva or hyphaema (blood in the anterior chamber)
- You are unable to see the posterior limit of a subconjunctival haemorrhage—this may indicate orbital fracture
- There is persistent pupil dilation—usually recovers spontaneously but may indicate a torn iris
- There are any signs of retinal damage (oedema and choroidal rupture) or
- If you cannot assess the eye, for example, due to lid swelling or pain
Arc eye
Arc eye is due to corneal epithelial damage as a result of exposure to ultraviolet light. It is seen in welders, sunbed users, skiers, mountaineers and sailors who do not use adequate eye protection. Symptoms include severe eye pain, watering and blepharospasm a few hours after exposure. Pad the eye and give analgesics and cyclopentolate 1% eye drops bd (causes pupil dilation). Recovery should occur within 24 hours—if not refer to eye casualty. Advise on suitable protective wear for future exposure.
Box 2. Rule of Nines—ignore areas of erythema only
| |||||||||||||||||
|
Scalds and burns |
|---|
|
TOPAbstractCommon injuries and the...WoundsNail injuriesForeign bodiesInsect and fish stingsMusculoskeletal injuriesFracture complicationsHead injuryEye traumaScalds and burnsReferences |
|---|
In all cases, if a patient presents following a burn, assess the cause, size and thickness of the burn. Use the ‘rule of nines’ to estimate the extent of the burn (Box 2). Partial thickness burns are red, painful and blistered, full thickness burns are painless and white or grey. Always consider NAI in children.
Sunburn
Sunburn is extremely common. Susceptibility depends on skin type. Tingling is followed 2–12 hours later by erythema. Redness is maximal at 24 hours and fades over 2–3 days. Desquamation and pigmentation follow. Severe sunburn may cause blistering, pain and systemic upset. Treatment is symptomatic with calamine lotion as needed (some also advocate application of vinegar) and paracetamol for pain. Rarely dressings are required for blisters or, in severe cases, hospital admission may be required for fluid management. Sunburn predisposes to skin cancer and photoageing. Take time to educate the patient about the sun safety code (Box 3).
| Box 3. The sun safety code Take care not to burn in the sun:
|
Management of all other burns
Remove clothing from the affected area and place the area under cold running water for at least 10 minutes or until the pain is relieved. Do not burst blisters. Prescribe or give analgesia. Refer all but the smallest (less than 5%) partial thickness burns for assessment in A&E. Refer all electrical burns to A&E and all chemical burns except those in which the burn area is minimal and pain free. Consider referral to A&E for smoke inhalation.
If managing burns in the community, check the patient's tetanus status (Fig. 1). Apply silver sulfadiazine cream (Flamazine) or Vaseline-impregnated gauze and non-adherent dressings and review for healing and infection every 1–2 days. Cover burns on the hands with flamazine and place the hand in a plastic bag. Elevate the hand in a sling and encourage finger movement. Refer if burns are not healed in 10–12 days.
Prevention of scalds and burns through public education is important. Children often sustain burns by pulling on the flex of boiling kettles or irons, pulling on saucepan handles or climbing onto hot cookers. Refer any children who have sustained accidental burns to the health visitor for follow-up.
Smoke inhalation
Refer all patients who have potentially inhaled smoke for assessment in A&E—a seemingly well patient can deteriorate later. Airway problems occur due to thermal and chemical damage to the airways causing oedema. Suspect if the patient has singed nasal hairs, a sore throat or a hoarse voice. Carbon monoxide poisoning may result in the classic cherry red mucosa—but this may be absent. Cyanide poisoning is commonly due to smouldering plastics and causes dizziness, headaches and seizures.
Chemical burns
Chemical burns are usually caused by strong acids or alkalis. Wear gloves to remove contaminated clothing. Brush away any remaining chemical powder. Irrigate the area with cold running water for at least 20 minutes. Do not attempt to neutralize the chemical—this can exacerbate injury by producing heat. Refer all burns to A&E (or eye casualty if the burn is to the eye) unless the burn area is minimal and pain free.
Electric shock
Electric shocks cause thermal tissue injury and direct injury due to the electric current passing through the tissue. Skin burns may be seen at the entry and exit site of the current. Muscle damage can be severe with minimal skin injury. Cardiac damage may occur and rhabdomyolysis can result in renal failure. Refer all patients for specialist management via A&E.
Key points
|
|
References |
|---|
|
TOPAbstractCommon injuries and the...WoundsNail injuriesForeign bodiesInsect and fish stingsMusculoskeletal injuriesFracture complicationsHead injuryEye traumaScalds and burnsReferences |
|---|
-
NICE. Head injury: triage, assessment, investigation and early management of head injury in infants, children and adults. (2007) Accessed via www.nice.org.uk/nicemedia/pdf/CG56NICEGuideline.pdf [date last accessed 30.05.2008].
Curriculum statement 15.4: ENT and facial problems. Accessed via www.rcgp-curriculum.org.uk/PDF/curr_15_4_ENT_&;_facial_problems.pdf [date last accessed 30.05.2008].
Curriculum statement 15.5: Eye problems. Accessed via www.rcgp-curriculum.org.uk/PDF/curr_15_5_Eye_problems.pdf [date last accessed 30.05.2008].
Curriculum statement 15.9: Rheumatology and the musculoskeletal system (including trauma). Accessed via www.rcgp-curriculum.org.uk/pdf/curr_15.9_Rheumatology_and_Musculoskeletal_System2.pdf [date last accessed 30.05.2008].
Resuscitation Council UK. Emergency medical treatment of anaphylactic reactions: guidelines for healthcare providers (2008) Accessed via www.resus.org.uk/pages/reaction.pdf [date last accessed 30.05.2008].
Simon C, O'Reilly K, Proctor R, Buckmaster J. Emergencies in primary care (2007) Oxford: Oxford University Press. ISBN: 0198570686.
CiteULike 
Connotea 
Del.icio.us What's this?
| ||||||||||||||||||||||||||||||||||||||||||||||||