The stable patient Many patients present without overt evidence of signi \201 cant injury: \200 Provide O 2 , secure venous access, and send blood for group and save. \200 Monit or SpO 2 , pulse, BP, and respiratory rate. \200 Administer minimal or no intravenous \202 uids. \200 Perform a FAST scan if possible to look for cardiac tamponade ( b p.346). Obtain a CXR (ideally postero-anterior (PA) erect). \200 Record an ECG. \200 Provide IV analgesia as required (see b p.320). \200 Consider tetanus status and the need for proph ylactic antibiotics (eg 1.5g IV cefuroxime \200\224 according to local policy). Cover the chest wound with a sterile dressing (for sucking chest wound \200\224 see b p.342). Drain any pneumothorax with a chest drain (having decompressed any tension pneumothorax \200\224 b p.328). Do not insert the drain through the wound (this i the risk of infection) . Refer all patients for admission, observation, formal wound cleaning, exploration, and clos ure. If the patient remains stable overnight, with no clinical or radiological abnormalitie s (on repeat CXR \211 6hr after the \201 rst), they may be safely discharged with arran gements for review. Carefully document the size, position and other features of the chest wound, remembering th e potential medicolegal signi \201 cance ( b p.402). 341 PENETRATING CHEST INJURY 1 The unstable patient Haemodynamic instability may be due to tension pneumothorax, massive h aemothorax, sucking chest wound, or cardiac tamponade. Treat each of these as outlined on b p.342 involving a senior surgeon at an early stage. Indications for thoracotomy Thoracotom y in theater will be required for signi \201 cant hemorrhage, which typically means: \200 > 1.5 L of free blood obtained by initial chest drainage, or. \200 > 200mL of blood dra ining per hr, via the chest drain. 342 CHAPTER 8 Major trauma Penetrating chest injury 2 Open chest injury An open wound between the pleural cavity and t he outside may cause respiratory insuf \201 ciency. When the chest expands on inspiration there is less resistance to air movement through the open chest wound than down the tracheo bronchial tree. Air \202 ow into the lungs is reduced and the lung collapses as air enter s the pleural space and produces a pneumothorax. Hypoxia develops rapidly. Features Look for respiratory distress, tachypnea, and cyanosis. Management \200 Provide high \202 ow O 2 . \200 Cover the chest wound with a square o f polythene or sterile dressing. \200 Secure 3 sides of the dressing to the chest wall wi th adhesive tape, leaving one side free. This will allow air to exit through the chest wall during expiration, but prevent air entry into the chest cavity. Insert a chest drain (not through the wound) to drain the pneumothorax. \200 Provide furt her resuscitation as necessary. \200 Call a thoracic surgeon to arrange formal wound clos ure. Cardiac tamponade Hemorrhage into the pericardial sac may compromise cardiac output. Contin uing bleeding leads to cardiac tamponade, culminating in cardiac arrest. Cardiac tamponade usually results from penetrating trauma but may occur after blunt trauma. Features Clinical diagnosis requires a high index of suspicion. The oft-quoted Beck \200 \231s triad comprises distended neck veins, hypotension, and muf \202 ed heart sounds. Ide ntifying muf \202 ed heart sounds is rarely easy in a noisy ED and neck veins may not be d istended in a hypovolaemic patient. Kussmaul \200\231s sign and pulsus paradoxus are classi cal, but rarely helpful. Investigation The investigation of choice is a FAST scan ( b p.346) in the ED resuscitation room to identify the presence of pericardial \202 uid. USS signs of cardiac tamponade in clude right ventricular collapse. Formal echocardiography is rarely available immediately. CXR and ECG are rarely helpful, but may exclude co-existent conditions (eg pneumothorax). Treatment \200 Provide O 2 , insert 2 IV lines, commence IV \202 uid infusion if severe ly shocked and monitor ECG. Request that the thoracotomy tray be made ready. \200 Contact the most senior available c ardiothoracic/general/trauma surgeon and anesthetist and alert the operating theater. If the patient \200\231s condition permits, arrange immediate transfer for thoracotomy in t heater. Theater thoracotomies have better outcomes than those done in the ED. 343 PENETRATING CHEST INJURY 2 If the patient deteriorates to a peri-arrest state, consider pericardiocen- tesis using a l ong 18G needle connected to a 20mL syringe and 3-way tap. Puncture the skin 1 \200\2232cm b elow the xiphisternum at 45 to the skin. Aspirate while advancing the needle cephalad, a iming towards the tip of the left scapula. ST and T wave changes, widened QRS or arrhythmia s imply that the needle has been advanced too far. Aspiration of a small amount of blood (eg 20 \200\22340mL) may improve cardiac output tempo rarily and \200\230buy time \200\231 to organize thoracotomy. \200 Pericardiocentesis is often unsuccessful due to clots which have formed in the pericardial sac and which cannot be aspirated. Perform immediate thoracotomy in the ED for cardiac arrest from penetrating trauma. Do not waste time on pericardiocentesis. Thoracotomy for cardiac tamponade Thoracotomy in the ED may be required in certain life-thr eatening emergencies, including cardiac arrest due to penetrating chest injury: the princip al aim is to decompress the pericardium and relieve tamponade. First exclude and treat othe r reversible causes of cardiac arrest (upper airway obstruction, b p.324; tension pneumotho rax, b p.328). Thoracotomy is not indicated for cardiac arrest following blunt injury. Procedure \200 Summon expert help (ED consultant; cardiothoracic, general or trauma surgeon; anesthetist) and proceed immediately. Do not wait. Whilst the thoracotomy tray is being opened, don gloves, a face shield and an apron, ensure that the patient is being ventilated with O 2 via a tracheal tube, and start external ches t compressions ( b p.49). Continue rapid IV infusion via multiple lines and obtain blood fo r transfusion. Standing on the patient \200\231s left side, abduct the left arm, stop chest com- pressions and open the left chest wall. Start the incision at the medial end of the 5th intercostal space and cut laterally just above the 6th rib into the axilla. Use a rib retractor to acce ss the thoracic cavity. If necessary, improve access further by continuing the incision med ially using strong scissors to cut through the sternum and into the right 5th intercostal s pace (clamshell thoracotomy). Speed is of the essence. \200 Identify the heart: carefully incise vertically through the bulging pericar- dium over its anterior surface, avoiding the left phrenic nerve. \200 Evacuate blood from the pericardial sac and identify the damage. \200 Place a \201 nger over the cardiac d efect and perform internal cardiac massage by compressing the heart between 2 \202 at han ds, with \201 ngers placed over defects. Close myocardial wounds using interrupted 4/0 pr olene sutures, using te \202 on or pericardial buttresses if necessary. Once sutures are i n place, stop internal cardiac massage and check cardiac rhythm and output. If the heart is \201 brillating, de \201 brillate using internal de \201 brillation paddles, by placin g a paddle over each side of the heart. Start with 5J energy initially, i as necessary to m ax of 50J. Use an external de \201 brillator if no internal paddles are available. Once a pulse has been restored, ensure that hypovolaemia is corrected. Give cefuroxime 1.5g IV, insert an arterial line and urinary catheter, recheck U&E, glucose, FBC, and clotting. The cardiothoracic surgeon will direct further surgical management. 344 CHAPTER 8 Major trauma Aortic injury The vast majority of aortic injuries ( \211\210 90 % ) are sustained during high energy blunt trauma (eg road traf \201 c collisions, high falls). Only a small propor tion of these patients reach hospital with signs of life. The usual site of rupture is just distal to the origin of the left subclavian artery, possibly caused by differential sheari ng forces between the mobile arch and the \201 xed descending thoracic aorta. An alternat ive proposed mechanism is that during rapid deceleration the \201 rst rib and clavicle sw ing down and directly \200\230nip \200\231 the aorta ( \200\230osseous pinch \200\231 theo ry). The injury is relatively unusual in children, who are perhaps protected by having more elastic tissues. Features Patients who reach hospital alive are most likely to have a partial or contained r upture, with a haematoma con \201 ned by aortic adventitia. They may complain of chest and back pain and there may be a harsh systolic murmur, absent or d pulses (with differential BP between arms and legs), and evidence of hypovolaemic shock: features of other signi \201 cant non- aortic injuries may predominate. Diagnosis The diagnosis of aortic injury can be dif \201 cult: adopt a high index of suspi cion. An erect CXR is invaluable provided that the patient \200\231s condition permits it. CXR features suggesting aortic injury include: \200 Widened mediastinum ( > 8cm on PA \201 lm). \200 Abnormal aortic arch contour. \200 Deviation of the trachea to the right side. \200 Deviation of an orogastric/NG tube to the right side (such that it lies to the right of the T4 spinous process). Depression of the left main bronchus > 40 below the horizontal. \200 Left pleural cap or fractured \201 rst/second ribs are often quoted, but are of little diagnostic value. \200 The CXR may be normal! Management Resuscitate and treat other injuries. Aortic injuries are associated with other severe chest injuries, eg \202 ail segments, pulmonary contusions. As a minimum, provide O 2 , insert two IV cannulae, start IV \202 uids, provide analgesia, monitor vital signs and SpO 2 . Check U&E, glucose, FBC, clotting, ABG, and cross-match. Insert urinary cathete r and arterial line. Involve a cardiothoracic surgeon or a vascular surgeon with expertise in aortic injury. Ref er urgently for specialist investigation (CT scan and/or aortography). Involve anesthetist/ ICU. Control BP (avoid over-infusion of IV \202 uids; use glyceryl trinitrate (GTN) infus ion IV to maintain systolic BP \211\210 90mmHg) prior to treatment. This usually involves open surgical repair, but some centers have reported good short-term results using endovasc ular stents. This page intentionally left blank 346 CHAPTER 8 Major trauma Focused assessment with sonography for trauma (FAST) scan Increasingly used in the ED resus citation room to assess the chest and abdomen of acutely injured patients, especially those with shock. Can be performed by a trained ED doctor, surgeon, or radiologist. Advantages \200 Can be done in ED. \200 Quick: takes 2 \210\222 3min. \200 Non-invas ive. \200 Repeatable if concerns persist or the patient \200\231s condition changes. Disadvantages \200 Operator dependent. \200 Does not de \201 ne injured organ, only pr esence of blood or \202 uid in abdomen or pericardium. Ideally performed with a portable or hand-held USS scanner. Looks at four areas for the presence of free \202 uid only: \200 Hepatorenal recess (Mo rrison \200\231s pouch). \200 Splenorenal recess. \200 Pelvis (Pouch of Douglas). \200 Pericardium. The scan is usually done in that order, as the hepatorenal recess is the \201 rst to \201 ll with \202 uid in the supine position, and is most easily identi \201 ed. If the indication for FAST scanning is to identify cardiac tamponade, the \201 rst view s hould be the pericardial view. Free \202 uid appears as a black echo-free area: \200 Between the liver and the right k idney. \200 Between the spleen and the left kidney. \200 Behind the bladder in the pelv is. \200 Around the heart in the pericardium. A positive FAST scan is one which identi \201 es any free \202 uid in the abdomen or in the pericardium. Visible free \202 uid in the abdomen implies a minimum volume of \211 \210 500mL. The \201 nding of blood in the pericardium after trauma is an indication for emergency thoracotomy, ideally in the operating theater; however, thoracotomy should be per formed in the ED if the patient arrests. FAST scanning requires training prior to use on trauma patients; there is a signi \201 can t false-negative rate in inexperienced hands. 1 1 See http://www.trauma.org/index.php/main/article/214/ 347 DIAGNOSTIC PERITONEAL LAVAGE (DPL) Diagnostic peritoneal lavage (DPL) DPL is helpful in situations where clinical evidence of intra-abdominal injury is equivocal and neither CT nor USS is available. DPL may also be us eful to search for intra-abdominal bleeding in shocked head-injured patients, or those whos e massive pelvic fracture is being externally \201 xed (see b p.466). DPL is used less of ten now that FAST scanning and CT have become more readily available. Also, some injuries a re treated conservatively (eg \200\230minor \200\231 splenic injury in children) and so a + ve DPL is of less value than a speci \201 c diagnosis made by CT. The open technique of DPL is shown below. Ideally, DPL is done by the surgeon who will perform the laparotomy if the DPL is + ve. How to perform diagnostic peritoneal lavage \200 Explain the procedure and obtain consent if conscious. \200 Ensure that the bladder has been decompressed by a urinary catheter. \200 Ensure that an orogastric/NG tube has been passed. \200 Enlist an assistant and br ight light. \200 Clean the skin with antiseptic and drape with sterile towels. \200 In \201 ltrate LA (1 % lidocaine with adrenaline) around the proposed site of incision. Make a vertical midline skin incision \211\210 3cm long at a point one-third of the distan ce from the umbilicus to the symphysis pubis. However, use a supra-umbilical site if the pa tient has lower abdominal scars, is pregnant, or has a pelvic fracture. Request that the as sistant exerts gentle pressure on the wound edges, in order to minimize bleeding. Divide the linea alba, identify the peritoneum and grasp it between 2 surgical clips. Gently bring the peritoneum into the wound and feel its edge between \201 nger and thumb to ensure that no bowel has been caught in the clips. \200 Make a tiny peritoneal incisio n, insert a peritoneal dialysis catheter (without the needle) and direct it downwards into the pelvis. Gently twist the peritoneal clip to obtain a good seal around the catheter. Attempt to aspirate any free \202 uid. If obvious enteric contents or > 5mL blood is aspirated \200\224 stop, the DPL is + ve and the patient requires a laparotomy. Infuse 1L of warmed 0.9 % saline. Keep the catheter and seal in place and allow 5min for the \202 uid to mix. Agitate the abdomen gently. Place the empty bag on the \202 oor and allow the \202 uid to siphon out. \200 Send \202 uid for laboratory analysis. Since a + ve DPL commits the surgeon to a laparotomy, an objective measurement is helpful. Close the abdomen in layers. Criteria for + ve DPL \200 Aspiration of > 5mL free blood or obvious enteric contents. \200 RBC count > 100,000/mm 3. \200 WBC count > 500/mm 3. \200 Food debris or other enteric contents (eg vegetable \201 bres). Note: air enters th e peritoneal cavity during DPL and may be visible on subsequent CXR or abdominal X-rays. 348 CHAPTER 8 Major trauma Blunt abdominal trauma Blunt injury to the abdomen may be isolated or associated with injur ies elsewhere. Evaluation of the abdomen may be particularly dif \201 cult in the latter s ituation. The mechanisms of injury responsible are diverse and include road traf \201 c co llisions, crushing injuries, high falls, and direct blows (eg kicks and punches). Remember that lower chest injury may be associated with splenic or liver injuries. Examination \200 Assess for hypovolaemia. Check pulse, BP, and capillary re \201 ll. \200 Look for bruising (eg \200\230lap belt \200\231 imprint). (Measurements of abdominal girth are unhelpful and unreliable as a means of assessing intra-abdominal hemorrhage). Feel for tenderness and evidence of peritonism. Listening for bowel sounds is not helpful: their presence or absence is not a discriminating feature. Check for femoral pulses. \200 Log roll to check for loin tenderness and back injury. \200 Examine the perineum and perform a rectal examination , checking perineal sensation, anal tone, rectal integrity/blood and in the male, the position of the prostate. A high-rid ing, \200\230boggy \200\231 or impalpable prostate may indicate urethral injury (see b p.3 52). Investigations The need for and choice of investigation depend upon individual circumstance s, local policy, facilities, and expertise. Patients who are haemodynamically unstable or w ho have peritonism require immediate referral for laparotomy. Perform urinalysis in all patients. A positive urinalysis is a marker for intra- abdominal solid organ injury, not just renal tract injury. Insert a urinary catheter in patients who present with haemodynamic disturbance or who are critically ill (unless there is evidence o f urethral injury, see b p.352). Perform a pregnancy test in all women of child bearing age . Serum amylase does not discriminate between those with signi \201 cant intra-abdominal inj ury and those without; it is unhelpful in the early stages of trauma resuscitation. Plain abdominal X-ray is rarely useful, unless associated bony injury or bowel perforation is suspected: free intraperitoneal gas may be demonstrated on an erect CXR. FAST (USS) provides a rapid, repeatable, non-invasive bedside test. It is operator-dependen t. Haemoperitoneum is identi \201 ed by scanning the hepatorenal and splenorenal recesses, and the pelvis. The pericardium can also be scanned to look for tamponade. See b p.346. CT scans are extensively used to evaluate abdominal injuries as well as identifying injuries in other regions (eg retroperitoneum, brain, chest). The major advantage of CT is the abili ty to diagnose the injured organ(s) within the abdomen and to quantify injuries (minor lace ration of liver or spleen vs. multiple deep lacerations with signi \201 cant haemoperitone um). 349 BLUNT ABDOMINAL TRAUMA Initial stabilization (see b p.320) \200 Provide O 2 . \200 Treat airway and breathing problems. \200 Insert 2 wide bore ( > 16G) IV lines. \200 Send blood for U&E, glucose, FBC, clotting screen, and cross-matching. \200 Give IV \202 uids according to initial e vidence of hypovolaemia and response to treatment. Give blood blood products early if un stable. \200 Provide IV analgesia as necessary (contrary to popular opinion, this does not compromise clinical abdominal evaluation). Consider the need for orogastric/NG tube and urinary catheter. \200 Involve a surgeon at an early stage. \200 Inform the senior surgeon, duty anesthetist and theater staff if an urgent laparotomy is needed. Further evaluation and treatment Once resuscitation is under way, further evaluation and tr eatment will depend largely upon the clinical situation: Haemodynamically unstable Refer urgently to a senior surgeon for laparotomy. Inform the ope rating theater and the duty anesthetist immediately. There is no need (or time) to attempt to de \201 ne the intra-abdominal injury. Damage control surgery should be considered in u nstable, acidotic or cold patients. Clinical peritonism Resuscitate as above, provide IV antibiotics (eg cefuroxime 1.5g) and r efer urgently to a surgeon for laparotomy. Haemodynamically stable, no peritonism Refer to a surgeon for further investigation and obs ervation. FAST (USS) and abdominal CT scans are very useful in further assessment of these patients. Depending on local policy, others may be appropriately managed with regular obser vations and clinical re-examination. Possible abdominal injury in the multiply injured These patients provide a diagnostic chall enge: tailor investigations and management to individual circumstances. FAST (USS) and DPL are rapid, simple, and useful tools to help to identify signi \201 cant intra-abdominal he morrhage in the multiply injured patient. CT has superior diagnostic accuracy, but it is ti me-consuming and requires transfer and IV contrast. If the patient is haemodynamically stab le, abdominal CT is conveniently performed simultaneously with head CT. A patient who is ha emodynamically unstable should be transferred to theater, never to the CT scanner. Abdominal trauma in pregnancy Involve a senior obstetrician and gynecologist at an early st age. USS can demonstrate fetal viability and look for signs of abruption and uterine ruptur e. Remember to check Rhesus/antibody status \200\224 b p.594. 350 CHAPTER 8 Major trauma Penetrating abdominal trauma Most penetrating abdominal injuries are caused by knives or gu ns. The size of the external wound bears no relationship to the severity of intra- abdomina l injuries. These injuries have medicolegal implications ( b p.403). Initial approach On receiving the patient, provide O 2 , secure venous access and resuscita te according to an initial assessment of: \200 Airway and cervical spine. \200 Breathin g. \200 Circulation. Obtain complete exposure at an early stage in order to check for add itional wounds to the chest, back, loins, buttocks, and perineum. Evaluation of abdominal injury Unless the patient presents with hypovolaemic shock, it may be dif \201 cult to decide the extent and severity of the abdominal injury on clinical gro unds. In addition to standard monitoring and palpation of the abdomen, perform a digital re ctal examination and (especially in gunshot injuries) check carefully for spinal cord/cauda equina injury ( b p.380). Investigations Urinalysis Check the urine for blood. Blood Check BMG, U&E, glucose, FBC, clotting, group and save/cross-match. X-rays Obtain an erect CXR if possible to check for free gas under the diaphragm and a supi ne abdominal X-ray to identify bullet fragments, etc. FAST (USS) FAST scanning will rapidly identify the presence of free intra- abdominal \202 uid which would mandate a laparotomy ( b p.346). DPL This is rarely helpful in penetrating injuries. Management \200 Give O 2 ; insert two IV cannulas and send blood as outlined above. \200 In the unstable patient, give IV \202 uid as necessary, but do not give excessive IV \202 uids \200\224 aggressive infusion worsens outcome. A systolic BP \211\210 90mmHg in a conscious patient is enough until the start of surgery. \200 Provide IV analgesia (eg t itrated increments of morphine) as required. \200 Give IV antibiotics (eg cefuroxime 1.5g + metronidazole 500mg). \200 Consider the need for tetanus prophylaxis ( b p.410). \200 Cover the wound with a sterile dressing. Never probe or explore the wound in the ED to tr y and de \201 ne depth and possible peritoneal penetration. Involve the surgeon early to d ecide further management. \200 Patients who are haemodynamically unstable, have gunshot w ounds, or have obvious protruding bowel contents require urgent resuscitation and immediate laparotomy. Cover protruding omentum or bowel with saline soaked sterile swabs and do not push it back into the abdomen. \200 Investigation and treatment of other patients varies according to local policy. Some patients may be managed conservatively with monitoring and close observation. 351 RENAL TRAUMA Renal trauma Most renal injuries result from direct blunt abdominal trauma, the kidney bein g crushed against the paravertebral muscles or between the 12th rib and the spine. Indirect trauma (eg a fall from a height) can tear the major blood vessels at the renal pedicle or rupture the ureter at the pelvi- ureteric junction. Penetrating injuries are relatively rar e. Many patients with renal trauma also have other important injuries, which may obscure th e diagnosis of the renal injury. Children are particularly prone to renal injuries. Trauma may uncover congenital abnormalities, hydronephrosis, or occasionally incidental tumors. Clinical features Most patients give a history of a blow to the loin or \202 ank and have loin pain followed by haematuria (which may be delayed). The loin is tender and there may be visible bruising or abrasions. Worsening renal pain may indicate progressive renal ischa emia. Perinephric bleeding can cause loin swelling and a palpable mass. Haematuria may be a bsent in severe injuries in which there are renal vascular tears, thrombosis or complete ur eteric avulsion. Investigations Look for and record visible haematuria and test for microscopic haematuria. Get venous access, send blood for FBC, U&E, glucose, clotting screen, and group and save. I VU was the standard investigation for suspected renal injuries, but this has been largely r eplaced by abdominal CT. If CT is not available, IVU can be used to elucidate the form and function of an injured kidney and con \201 rm a functioning contra-lateral kidney. An unst able patient requiring immediate laparotomy may need an intra-operative IVU to diagnose a r enal injury and to check that the other kidney is functioning. CT Urgent abdominal CT is ne eded if there is frank haematuria or if the patient was shocked (but is now stable) and has frank or microscopic haematuria. The surgical team should be involved before CT is arrange d. Patients should be haemodynamically stable for transfer to CT. IVU is unnecessary if con trast enhanced CT is planned or has been done. FAST (USS) shows renal morphology and con \201 rms the presence of two kidneys, but does not demonstrate function. Selective angiography is occasionally helpful. Stable patients with isolated microscopic ha ematuria do not need urgent IVU or CT, but require review and appropriate follow-up. Management Most blunt renal injuries settle with bed rest and analgesia. Give prophylactic antibiotics after consulting the surgical team and according to local policy. Repeat and re cord pulse, BP, and T . Patients with penetrating renal injuries and severe blunt renal trauma need urgent expert urological assessment emergency surgery: the warm ischaemic ti me of a kidney is only \211\210 2hr. Resuscitate with IV \202 uids and give IV analgesia and antibiotics. 352 CHAPTER 8 Major trauma Bladder, urethral, and testicular trauma Bladder injury Most bladder ruptures are into the peritoneal cavity, caused by direct blows to the lower abdomen. These injuries often occur in people with distended bladders. Bone fragments from a fractured pelvis may also penetrat e the bladder ( b p.466). Clinical features Lower abdominal pain peritonism may be assoc iated with haematuria or an inability to pass urine. Look for perineal bruising and blood a t the external urethral meatus. Perform a rectal examination to check for the position of t he prostate and the integrity of the rectum. Investigations and management X-ray the pelvis to check for fractures. If there is no sign of urethral injury, pass a catheter to check for haematuria. Refer to the urology team. A c ystogram will show extravasation from a bladder injury. Intra-peritoneal ruptures need lapa rotomy and repair. Extraperitoneal ruptures may heal with catheter drainage and antibiotics . Urethral injuries Posterior urethral tears are often associated with pelvic fractures. Uret hral injury may also result from blows to the perineum (especially falling astride). Look for perineal bruising and blood at the external urethral meatus and perform a rectal e xamination (an abnormally high-riding prostate or inability to palpate the prostate imply u rethral injury). If urethral injury is suspected, do not attempt urethral catheterization, but refer urgentl y to the urology team. Some urologists perform a retrograde urethrogram to assess urethral injury, but many prefer suprapubic catheterization and subsequent imaging. Penile injuries See b p.523. Testicular trauma Injury to the scrotum/testis may result in a scrotal haematoma or testicu lar rupture. Both conditions require good analgesia. Further treatment depends upon the exa ct diagnosis. USS may help to distinguish between scrotal haematoma and testicular rupture. Scrotal haematoma may respond to conservative measures. Testicular rupture requires urgent surgical exploration and repair. Scrotal injuries Wounds involving the scrotal skin may need to be sutured (preferably with absorbable sutures) \200\224 most heal rapidly. Refer for investigation if there is comple te scrotal penetration with the attendant risk of damage to the testis, epididymis or vas d eferens. If the testis is visible through the wound, refer for surgical exploration and rep air in theater. This page intentionally left blank 354 CHAPTER 8 Major trauma Head injury: introduction The size of the problem Many patients with serious or fatal traum a have suffered a head injury. Additionally, minor head injuries are a frequent reason for attendance at an ED. Blunt injury is far more common than penetrating injury. Common causes of head injury \200 Road traf \201 c collisions of all types. \200 Falls . \200 Assaults. \200 Sporting and leisure injuries. \200 Workplace injuries. \200 Other mishaps. Pathophysiology Brain injury may be primary or secondary. Primary injury occurs at the time of the head injury. This takes the form of axonal shearin g and disruption, with associated areas of hemorrhage. This primary damage may be widesprea d ( \200\230diffuse axonal injury \200\231) or localized (eg \200\230contre-coup \200\231 frontal contusions in a fall hitting the occiput). Secondary injury occurs later, due to various problems that commonly co-exist. Many of thes e are preventable or treatable, and should thus be the focus during resuscitation: \200 H ypoxia. \200 Hypovolaemia and cerebral hypoperfusion. \200 Intracranial haematoma with localized pressure effects and i ICP. \200 Other causes of i ICP, including cerebral oede ma and hypercapnia. \200 Epileptic \201 ts. \200 Infection. The role of intracranial pressure Once the skull sutures have fused, the cranium is a close d box. Thus, a small i in volume (eg from swelling or haematoma) results in a large i in IC P (see Fig. 8.6 ). As ICP i , cerebral perfusion pressure d , since: Cerebral perfusion pressure = Mean arterial pressure \200\223 ICP Once cerebral perfusion pressure falls <70mmHg, signi \201 cant secondary brain injury may occur. Control of ICP and BP (including avoiding wild swings in BP) is an important treatm ent goal, especially as the normal cerebrovascular auto-regulatory mechanisms are impaired after head injury. Cerebral arterioles remain sensitive to p CO 2 , however, with an i p CO 2 resulting in marked arterial vasodilatation and unwanted i ICP. Controlling p CO 2 to wi thin normal levels is therefore important. i ICP produces a diminishing conscious level and causes herniation of the temporal lobe through the tentorial hiatus, compressing the oculo motor nerve, resulting in ipsilateral pupillary dilatation. This may progress to contralate ral hemiparesis and brainstem compression with cardiorespiratory arrest. i ICP leads to a r e \202 ex i in systemic arterial BP together with bradycardia: this combination is the Cus hing response . 355 HEAD INJURY: INTRODUCTION Indications for referral to hospital Any one of the following criteria indicates the need f or hospital assessment: \200 Impaired conscious level at any time. \200 Amnesia for the incident or subsequent events. \200 Neurological symptoms (vomiting, severe and persiste nt headache, seizures). Clinical evidence of a skull fracture (cerebrospinal \202 uid leak, peri-orbital haematoma). Signi \201 cant extracranial injuries. \200 Worrying mechanism (high energy, possible no n-accidental injury, possible penetrating injury). Continuing uncertainty about the diagnosis after \201 rst assessment. \200 Medical co-m orbidity (anticoagulant use, alcohol abuse). \200 Adverse social factors (eg alone at hom e). The following are highly recommended: \200 The SIGN (Scottish Intercollegiate Guideli nes Network) guideline on head injury is accessible at www.sign.ac.uk The NICE (National Institute for Health and Clinical Excellence) clinical guidelines on hea d injury published in 2007 and accessible at www.nice. org.uk e r u s s e r p l a n a r c a r t n i I Intracranial blood volume Fig. 8.6 ICP according to intracranial blood volume. 356 CHAPTER 8 Major trauma Head injury: triage and monitoring Triage Every ED requires a system for the rapid initial assessment of head-injured patients. The exact system will depend upon local policy, expert ise and facilities. It must enable patients with signi \201 cant injuries to receive immed iate resuscitation and ensure urgent treatment of those patients liable to complications. E xperienced nursing staff can quickly identify those patients in need of urgent attention, b ased upon: \200 The mechanism of injury. \200 History from the ambulance crew. \200 A n assessment of vital signs. \200 Conscious level according to the Glasgow Coma Scale ( b p.361). \200 Limb power. \200 Pupil responses. \200 BMG. For patients who are haemod ynamically stable, alert and orientated , with no neurological de \201 cit and an apparent ly minor head injury, it is appropriate to proceed to obtaining a full history, as outlined on b p.358. For patients with multiple injuries and/or a serious head injury , there will be no time initially to obtain a full history. Instead, proceed rapidly to initial assessme nt and resuscitation. During the \201 rst few seconds, it is useful to obtain an impressi on of the severity of the head injury. One simple method (AVPU) classi \201 es patients ac cording to their response to stimulation: \200 A lert. \200 Responsive to V oice. \200 Responsive only to P ain. \200 U nresponsive. If a patient is unresponsive or responds only to pain, call for senior ED help and an ICU specialist or anesthetist, since expert ai rway care (RSI, tracheal intubation and IPPV) will be needed. Monitoring Every head-injured patient requires regular neurological observations. These sho uld include measurements of GCS, pupil response, limb power, pulse, BP and respiratory rate on a standard chart, such as the one shown in Fig. 8.7 . This monitoring is critical if co mplications such as intracranial haematomas, \201 ts and hypovolaemia from other injuries are to be detected and treated at an early stage. Any deterioration in GCS is an emergency : re-examine the patient and correct identi \201 able problems promptly whilst obtaining u rgent senior help. 357 HEAD INJURY: TRIAGE AND MONITORING NAME UNIT No D. of B. WARD NEUROLOGICAL OBSERVATION CHART TIME DATE 4 3 2 1 5 4 3 2 1 6 5 4 3 2 Spontaneously To speech To pain None Oriented Confused Inappropriate Words Incomprehensible Sounds None Obey commends Localize pain Normal Flexion Abnormal Flexion Extension to pain None Eyes closed by swelling =C Eyes Open C O Endotracheal tube or Tracheostomy =T M Best verbal response A S C Usually records the best arm response A L E Best motor response 1 240 230 220 210 200 190 180 170 160 150 140 130 120 110 100 90 80 70 60 50 40 30 26 22 18 1 4 1 40 39 38 37 36 35 34 33 32 31 30 2 T e m p e r a t u r e 3 C 4 5 Blood pressure and Pulse rate 6 7 8 Respiration Pupil scale (m.m.) 10 6 Size Reaction Size Reaction + reacts \200\223 no reaction c. eye closed right PUPILS left L I M B Normal power Mild weakness Severe weakness Spastic flexion Extension No response A R M S Record right (R) and left (L) separately if there is a difference between the two sides. M O V E M E N T Normal power Mild weakness Severe weakness Extension No response L E G S Fig. 8.7 An example of a neurological observation chart. 358 CHAPTER 8 Major trauma Head injury: history It may be impossible to obtain a complete history from the patient, pa rticularly if there was loss of consciousness and/or amnesia. Use all available sources of information, including friends and family, other witnesses, and the ambulance crew. Cover t he following areas: Mechanism of injury Eliciting the exact mechanism of injury will provide an impression of t he nature of the forces involved and the risk of subsequent complications. Consider the pos sibility that the head injury may have been preceded and caused by another medical problem (eg arrhythmia, epilepsy, diabetes). Time of injury This information is useful, but may not be known. Loss of consciousness/amnesia A period of unconsciousness implies a head injury of at least moderate severity. It can be dif \201 cult to establish exactly how long unconsciousness lasted, particularly if there is associated amnesia. Document the length of amnesia (both b efore and after injury), but remember that the full extent of the amnesia may not become ap parent until much later. Subsequent symptoms Some symptoms are relatively common after head injury (eg headache and vomiting) \200\224 many patients will complain of these without being directly asked. Ther e are a number of other symptoms, however, which the patient may not mention unless speci \201 cally asked. Enquire about the following symptoms: \200 Headache. \200 Nausea and vomiting. \200 Limb weakness. \200 Paraesthesiae. \200 Diplopia. \200 Rhinorrhoea. \200 Otorrhoea. Past medical history Document pre-existing illnesses and symptoms, particularly those that may have caused the head injury (eg cardiac arrhythmias, epilepsy, diabetes), or might make the consequences more severe (eg bleeding tendency). Enquire about previous head injury (a n old skull fracture visible on new X-rays may otherwise be confusing). Drug history Ask particularly about recent alcohol and other drug ingestion and whether or not the patient is taking anticoagulant drugs (eg warfarin). This is very important, since patients with bleeding disorders and/or on anticoagulants have a much higher risk of intrac ranial problems after head injury, often require CT and must be admitted to hospital ( b p. 366). 359 HEAD INJURY: HISTORY Social history Before contemplating discharge of any head-injured patient, \201 nd out if there is a responsible adult at home, or if there is someone else with whom the patient co uld go and stay. Tetanus status If there are any wounds, consider the need for tetanus prophylaxis. 360 CHAPTER 8 Major trauma Head injury: examination Resuscitation proceeds with examination, according to problems ide nti- \201 ed in the primary survey. Follow initial brief neurological examination (GCS, p upil reactions, limb weakness) by de \201 nitive complete examination: Cervical spine injury Consider this possibility in all cases (see b p.320). Glasgow Coma Scale Determining the conscious level is a crucial part of the neurological ex amin- ation. The adult score ranges from a minimum of 3 to a maximum of 15 and is calculate d as shown in Table 8.2 . Repeated GCS recordings are a crucial part of monitoring the head injured patient. A fall in GCS indicates a poten- tially serious deterioration and mandate s a search for correctable conditions. Vital signs Record pulse, BP, and respiratory rate. BMG This is essential in all patients with altered conscious level. Alcohol Record if the patient smells of alcoholic drinks but never assume d GCS is due to a lcohol.