Specific Injuries Of Importance

Having discussed the initial assessment of the injured patient, emphasis is placed on specific injuries of importance. These injuries are critical in that they are identified during the primary survey, represent impending demise, and require an immediate response.

Traumatic Arrests In most emergency medical systems, paramedics transport patients without vital signs to a hospital while cardiopulmonary resuscitation (CPR) is initiated (unless obvious signs of death are present). On arrival to the Emergency Department (ED), a critical decision must be made regarding the level of intervention. A recently published large series analyzing 862 patients undergoing ED thoracotomy at a regional trauma center yields interesting information. 12 There were 385 patients (45 percent) with blunt trauma, 147 (17 percent) with stab wounds, and 330 (38 percent) with gunshot wounds. The overall number of neurologically intact survivors was 34 (3.9 percent), and the series was large enough and sufficiently equally divided among mechanisms of injury to permit subgroup analysis. There were 259 patients with blunt trauma and no vital signs in the field. There were no survivors in this group. This is a consistent finding among other series, and clearly ED thoracotomy for this group of patients should be abandoned. The greatest proportion of neurologically intact survivors was among patients with stab wounds to the chest (20 of 109, 18 percent). Their survival rate improved to 23 percent among thoracic stab wound victims with vital signs in the field and to 38 percent among those who were moribund but had some vital signs on arrival to the ED. Therefore, the strongest recommendation for ED thoracotomy can be made for victims with penetrating chest trauma with witnessed signs of life in transport or the ED and at least cardiac electrical activity on arrival. "i3,!4 andl5 More liberal indications (although not with total consensus) would include victims with abdominal trauma with cardiac electrical activity, in whom thoracotomy is performed for resuscitation and aortic cross-clamping before operating room laparotomy rather than for hemorrhage control, and patients with blunt torso trauma who have some vital signs on arrival.

Severe Head Trauma Head trauma with coma (GCS 3 to 8) suggests that rapid assessment of the intracranial injury must be undertaken and the patient should be intubated for airway protection and to avoid secondary brain injury associated with hypoxemia. These patients present a dilemma, because ultimately they may be found to have anything ranging from a normal head CT scan to a devastating, nonsurvivable brain injury. The challenge is to quickly identify patients with intracranial injuries that may benefit from neurosurgical evacuation. In such cases, minutes may make a difference in the ultimate patient outcome. Accordingly, all nonessential procedures should be prioritized to a time after the head CT is performed. The patient is intubated with in-line neck immobilization, and the C-spine collar is reapplied. A rapid chest x-ray may be justifiable to rule out pneumothorax and to assess endotracheal tube placement, particularly if the film can be developed as the patient is being transported to the CT scan suite. This implies that in the well-run trauma center the critically multisystem-injured patient has ongoing diagnostic workup and therapeutic resuscitation occurring in a smooth transition between ED, x-ray suite, operating room, and postoperative intensive care setting.

Tension Pneumothorax, Open Pneumothorax, and Massive Hemothorax These are all diagnoses that should be made during the primary survey requiring rapid placement of a chest tube. Absent breath sounds on the side of a gunshot wound, stab wound, or chest wall ecchymosis (associated with tympany in the case of pneumothorax and percussion dullness in the case of hemothorax) in a patient with respiratory distress and tachycardia suggest the diagnosis.

Abdominal Gunshot Wounds with Hypotension This deserves special mention. Palpation tenderness elicited on ED admission identifies the need for surgery and should prompt immediate transport to the operating room without further workup. Placement of nasogastric, urinary, and intravenous catheters should proceed in the operating room as the patient is being prepared for general anesthesia. The importance of time is emphasized because of the large amount of hemorrhage necessary (>2 L in the 70-kg patient) to produce severe hypotension in a young, previously healthy patient. A false sense of security with these patients brought on by the absence of hypotension is hazardous.16

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