Options include moving the patient to the operating room, admission to the hospital, or transfer to another facility. The primary and secondary survey must have been completed, and a gastric tube and a Foley catheter should be in place unless a urethral injury was detected. In most urban hospitals, the trauma surgeon should have been present for the secondary survey, and he or she should assume direction of the diagnostic workup and disposition of the case at that time. In rural hospitals that transfer severe trauma cases, the resuscitating physician should relate all the physical findings discovered during the primary and secondary surveys to the physician receiving the patient. Laboratory results, x-rays, and the flow sheet showing blood pressure, pulse, fluids infused, urine output, gastric output, and neurologic findings should accompany the patient. If a diagnostic peritoneal lavage was performed, a sample of the lavage fluid should accompany the patient. A patient who is being transported to another facility should be accompanied by personnel capable of administering fluids and monitoring vital signs and pupillary changes. Mannitol should be available if there is neurologic deterioration enroute.
The hallmark of trauma care in patients without obvious indications for surgery identified on the initial assessment is serial examination. An observation area is extremely useful for these patients. Such an area (typically with nursing care provisions analogous to those of an intermediate care unit in most hospitals) allows for serial observations of patients with (1) closed head trauma who have regained consciousness but require repeat neurologic examinations, (2) penetrating abdominal wounds (stab wounds or tangential gunshot wounds) who require repeat abdominal examinations, (3) patients receiving repeat chest x-rays for penetrating chest trauma without pneumothoraces, (4) blunt abdominal trauma with normal physical examination on initial evaluation, and (5) documented blunt injuries to the liver, spleen, or kidney who are clinically stable and are being managed nonoperatively. An observation area for these patients should allow for more rapid triage from the ED and for serial evaluations of multiple patients in a convenient setting and should provide for rapid transport to the operating room in patients whose clinical examination deteriorates.
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