Therapy of Trauma

Therapy of Trauma
The elevation of a traumatized area is the most important initial treatment of an injury. It should be elevated as soon as possible twelve to sixteen inches above the level of the heart to decrease bleeding and capillary pressure. This is critical the first three to seven days after the injury. Lack of elevation is the cause of the thumping and pounding of your pulse at the injury site which, in turn, results in swelling and pain. Ice or cold slows circulation at an injury site and decreases bleeding. Ice should be placed gently against the wound about 5 to 20 minutes per hour as tolerated. This should be done for at least the first 5 to 7 days, and depending on the injury, up to 10 to 12 days after the injury. Ice in an ice bag or blue ice pack should have at least a half inch layer of a thick towel against the skin. The object is to cool, but not to burn, freeze, or damage any healthy superficial tissues and cause other substantial secondary damage and problems.
Heat is usually good only after about 7 to 12 days. This depends on the size and amount of damage as well as the damaged site. Ask your doctor about the specifics of your injury at this later time. Heat allows the damaged blood vessels to heal by increasing the circulation for repair. Early heat to a new acute injury will definitely increase bleeding, swelling, and pain. It will lengthen the recovery time and induce future pain. Don't immediately use heat after a new injury. Heat should only be on low, not hot or high: the objective is gentle warming. A heating pad on low heat with at least half inch layers of a thick terrycloth towel under the site will provide gentle warming therapy. An external ace bandage, gently and lightly applied, may compress a new injury causing a stopping or slowing of the bleeding and controlling the pain and swelling. An ace should never be applied too tightly. Never sleep with a boot, ace or splint applied. This includes even a short nap. You may awake with permanent nerve or circulatory damage.
Movement of the joints propels lymphatic fluid back towards the heart and reduces swelling. Occasionally with elevation, gravity helps this movement. This extension and flexion of the joint proximal to the injury pumps traumatic fluids away from the injury back towards the heart. After several days, gentle movement and pumping of lymphatics reverses swelling at the site and promotes healing and circulation. Bend your joints as tolerated or directed by the physician several times per hour after a few days. A fracture, tendon strain or pull, or partial or complete tendon tear, should be initially immobilized with a splint. Splints decrease movement and range of motion of joint. This lack of movement decreases bleeding and swelling and helps limit further damage. This increases healing and limits damage so further bleeding or problem doesn’t occur.
If one is wearing an ace or splint, it is important to periodically perform a capillary refill test. Do this by squeezing a toe nail or fingernail distal to the injury. Release the squeezing pressure and count how long it takes the nail to pink up again. It should be 1 to 2 seconds. If it is longer or incomplete, loosen the ace or splint and repeat these steps. If the test remains abnormal, seek immediate medical attention. The pressure within the tissue is increased and could permanently damage a nerve, a blood vessel, or even the entire distal extremity.
Casting is usually a poor idea on the first day of most traumatic injuries. Casting immobilizes a newly damaged part of the body and finitely surrounds it. This space restriction does not initially allow for the further expansion or swelling which occurs for the first 3 to 5 days after trauma. It does not allow for the lack of elevation on the part of the patient; the non-elevated injury will have further swelling or edema and can be an extremely dangerous proposition. Therefore, in some orthopedic injuries, the orthopedic surgeon can be most valuable after 3 to 5 days to evaluate the stabilized problem. As an example, a fracture of the thighbone may bleed more than 1 to 4 pints of blood. Usually the vast amount of bleeding is not clearly appreciated. However, it must be understood to correctly treat the injury.

Casting an injury too early could dangerously compress the injury and therefore drainage ports are often placed by the surgeon. Therefore: Ice, elevation, and light compression really help new injuries, big and small. No heat should be applied for at least 7 to 10 days.
Anti-inflammatory medicines, such as ibuprofen, aspirin, and naproxen all help to remove pain as well. However, they may cause bleeding and make the situation worse. Acetaminophen relieves pain and does not cause bleeding. Other pain pills can and do work better individually or in combination with narcotics. Non-narcotics need to be adjusted specifically for you. There are many very age specific health, and side effect considerations to be discussed with the doctor. Pure narcotic pain pills remove pain by blocking the pain receptors in the brain. They usually do not cause bleeding but some do. They do not fix the problem and can cause constipation and addiction. They may block the pain, but constant use may actually add danger to the situation. Other pain pills can decrease swelling and may partially increase some bleeding, but not as much as good preventative care, elevation, and immobilization. Certain non-steroidal anti-inflammatory injectables (NSAIDS) really work better than the pill forms available. Follow the experienced physician's directions carefully; follow up care with the physician is essential in a few days.
Never sleep with an air boot, cast, splint or an ace bandage. This can possibly cause permanent nerve palsy or vascular compression. Have you ever slept on your arm or hand and awoke in pain until you could get the circulation going again? With pain medications removing pain and a cast compression of the injury, you could get permanent tissue damage. Nerve and blood vessel compression and damage may dangerously occur with serious results. If not cared for immediately and appropriately, compression and constriction can possibly result in permanent paralysis and even amputation or deformity. Always have a doctor consistently follow up and re-evaluate your care. You must consistently monitor the area of trauma and be aware of pitfalls and complicating circumstances.
John Drew Laurusonis, M.D.
Doctors Medical Center