Angle grinder injury: embedded fragment, free bleeding and early shock
10:45 in a joinery workshop. A 41-year-old bench hand has been injured by an angle grinder kickback. He is sitting on the floor holding his left forearm; there is a deep 6 cm laceration on the inner forearm and a 2 cm sliver of cutting disc embedded in the wound. Blood is running freely and there is a pool about 20 cm across on the floor. He is pale, his skin is clammy, he says he feels sick and light-headed, and his radial pulse feels fast and weak at about 120 per minute; his breathing is 26 and shallow. He is fully alert but frightened. Two workmates are nearby, one of whom is holding a rag he wants to press on the wound. The first aid kit is on the wall 15 m away, the AED is at reception, and the ambulance has been called with a 12-minute ETA. There is a sharps bin in the office, not in the workshop.
1. How do you control this bleeding with a fragment embedded in the wound?
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First, the basics. Gloves on before I touch anything. Ask him to lie down rather than sit - he is already showing signs of shock and lying down helps. Send one workmate for the kit; keep the other for help.
The fragment is the judgement call. It stays where it is. It may be plugging the vessel, and pulling it out can release a torrent of bleeding and cause further tissue damage. I do not press on it.
Technique:
- Expose the wound enough to see what I am doing; the rag can be replaced with a sterile dressing, but pressure matters more than sterility at this point.
- Place a dressing or pad on each side of the sliver, then build pads up around it so that firm pressure is applied to the wound edges, not to the object.
- Bandage firmly over the pads to hold the pressure, leaving the fingers visible so I can check colour, warmth and capillary refill.
- Elevate the arm if it does not increase his pain.
- If blood soaks through, add another pad on top - never lift the first one off to look.
If bleeding is still catastrophic despite this and a tourniquet is available and I am trained to use it, that is the next step on a limb; otherwise keep firm pressure and get him to hospital fast.
2. How do you recognise and manage the shock, and what must you not do?
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Recognition. Pale skin, clammy sweat, nausea, light-headedness, pulse about 120 and weak, breathing 26 and shallow, after a significant external bleed. That is the classic picture of hypovolaemic shock - not enough circulating volume for the heart to maintain blood pressure. He is conscious now, but he can deteriorate quickly.
Management:
- Lie him flat and raise his legs, unless I suspect a leg or pelvic injury.
- Keep controlling the bleeding - that is the treatment for the cause.
- Keep him warm: coats, foil blanket, away from the draught of the workshop door.
- Loosen anything tight at the neck, chest or waist.
- Reassure him, stay with him, and keep talking.
- Monitor breathing, response and pulse every few minutes, and note the times.
What not to do:
- Nothing by mouth - no water, no tea, no painkillers and no aspirin. He may vomit, and he may need surgery.
- Do not let him stand or walk to the ambulance.
- Do not remove the embedded fragment or lift the pressure dressing.
- Do not leave him alone; if he becomes unresponsive and stops breathing normally, that is a cardiac arrest and I start CPR.
3. What infection-control steps do you take, and what does your written record contain?
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Infection control. Gloves for me, and an apron if one is in the kit; eye protection if there is any risk of spatter when the dressing is changed. Any cuts on my own hands are covered before I start. I keep the wound covered rather than letting him hold a workshop rag against it. Blood-stained dressings and gloves go into a clinical waste bag - if there is none in the workshop, double-bag them and seal, and never into the general bin. The contaminated disc fragment is left for the ambulance crew; I do not pick it out or put it in the office sharps bin myself. Hand hygiene after removing gloves, and clean the floor area with the spill procedure the firm uses.
Record: date, time, location; his name, job and date of birth; mechanism (grinder kickback); wound description and the embedded fragment; observations - pulse 120 weak, breathing 26, pale and clammy; treatment given with times (pressure around the object, dressing, elevation, lying down, warmth); that nothing was given by mouth; the 999 time; who took over. Sign and date it. I would also flag to the employer that this is a serious injury which may be reportable under RIDDOR by the responsible person, and that the accident book entry should match my record.