Trauma basics - 5
Important Hypoxia and hypotension kill head-injured patients.
Radiological investigations
The standard trauma X-rays are of the chest, cervical spine and pelvis. These X-rays do not need to be performed if there is no clinical indication.
Other X-rays are ordered according to the findings of the physical examination.
Skull X-rays are NOT indicated unless there is the possibility of depressed skull fracture, compound skull fracture or cranial foreign body.
Skull X-rays are not sensitive or specific for brain injury.
Head trauma associated with depressed levels of consciousness requires CT scan
Can we abolish skull x-rays for head injury?
Paediatric minor closed head injury.
Pathology tests needed
- Send blood for U&E, FBE, cross match.
- Arterial blood gases to assess ventilatory and pulmonary function and acidosis.
Ultrasound
Trauma ultrasound is a useful part of the secondary survey, providing it is done by appropriately trained doctors, and does not impede the resuscitation process.
Cystourethrogram (retrograde)
Indicated whenever there is a suspicion of ruptured urethra.
Use 20 ml of water soluble contrast initially via a catheter placed just inside the meatus.
If there is extravasation of contrast, an urgent urological opinion is necessary, as the bladder may need to be drained suprapubically.
The medieval looking contraption below is a tool for performing this investigation, but most doctors tend to use the catheter method.
Arteriograms
May be indicated in peripheral limb trauma - consult with vascular surgeon.
Arch aortogram was until recently the gold standard in the diagnosis of ruptured aorta (suspect in severe blunt chest trauma associated with widened superior mediastinum > 8 cm and/or fractured 1st rib and/or multiple rib, sternal fractures). CT chest is now used for this.
CT - Computerised Tomography
CT scan of head is indicated in all head injuries where the
- GCS is less than 13.
- significant loss of consciousness or amnesia.
The Canadian CT Head rules are a useful, although not yet prospectively validated, checklist of criteria indicating significant intracranial injury.
Do not assume a depressed level of consciousness is due to intoxication just because a patient smells of alcohol.
CT scanning of a patient's abdomen is increasingly being performed, as it prevents unneccessary laparotomies, however a haemodynamically unstable patient needs an urgent laparotomy, not a CT.
DPL - Diagnostic Peritoneal Lavage
There is rarely any indication for DPL if more sophisticated imaging is available, as DPL is not sensitive or specific for significant intra-abdominal injury.
Ultrasound or CT Abdomen now preferred.
If the blood pressure is unstable and abdominal injury is suspected, then emergency laparotomy is indicated and time should not be wasted performing either DPL or CT.
Secondary & Definitive Treatment
According to the findings of the secondary survey, the definitive treatment of the patient can be arranged once the initial resuscitation of life threatening conditions is underway and the patient is reasonably stable.
If primary resuscitation fails to control the situation the patient must be transferred immediately to the operating suite. Inform anaesthetists and surgeons early.
In less critical situations the patient may be held in the Emergency Department pending transfer to the operating room or may be sent to a ward or the intensive care unit
Fractures should be splinted in the ED. Joint dislocations must be reduced and splinted (especially ankle, knee and elbow).
Minor lacerations should be cleaned and sutured, otherwise sterile dressings should be applied. Major lacerations and soft tissue defects should be covered with saline or iodine soaked combine.
Burns to the body (not face) may be dressed with SSD cream.
Antibiotics, tetanus
Intravenous antibiotics, usually a second or third generation cephalosporin are indicated for any open wounds.
Tetanus prophylaxis if indicated.
Pain - general
There are absolutely NO contraindications to analgesia, which should usually be with incremental intravenous morphine.
Non-steroidal anti-inflammatory drugs (e.g. ketorolac, indometacin) are also useful, but should be avoided in patients with pre-existing renal impairment or renal injury [direct e.g. trauma or indirect e.g. crush injury, prolonged hypotension].
Pain - local
Regional nerve blocks particularly femoral nerve block for fractured shaft of femur are effective.
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