Disorders of the central nervous system: The central nervous system should be quickly assessed by ascertaining the level of consciousness, spinal cord function and pupillary response to light. Conscious level is assessed by recording patient eye opening and motor response to various stimuli. These are graded as spontaneous, in response to direct questioning, uncomfortable stimuli or none at all. All four limbs should be tested for response to assess spinal cord function.

Exposure: all multiple injured patients should be completely undressed. Clothes are cut off if necessary to minimise undesirable movement. This allows a thorough survey of injuries. The patient should, however, not be allowed to become hypothermic- and should be kept covered when possible and the resuscitation room should be warm. Injured children lose heat rapidly when exposed (even in hot environments), particularly if they are wet.

During the course of the primary survey, the four most important rules to remember are:

1. The patient should be repeatedly reassessed, particularly if clinical signs change.

2. Any immediately life threatening condition diagnosed should be rectified without delay.

3. Penetrating wounds and implements must be left for formal surgical exploration.

4. Any external bleeding should be stopped by using direct pressure.

 
Secondary Survey

Following the initial survey and resuscitation, the patient should undergo a thorough secondary survey with the aim of documenting any other injuries. During this survey, however, the basics of the primary survey (airway, breathing and circulation) should be regularly reassessed to detect any unexpected deterioration. The patient is best examined from head to foot by the team leader. Tetanus immunisation and prophylactic antibiotics can be administered if necessary. A history should be obtained and finally, the standard radiographs of the lateral cervical spine, chest and pelvis are taken. (Remember however, that lateral cervical spine radiographs may fail to reveal up to 20% of injuries). The temperature of the patient should be recorded. This may require the use of a low reading thermometer. Remember to keep the patient covered unless an examination or procedure is being carried out.

History: during the course of the secondary survey the following points must be clarified:

• Allergies

• Medications and tetanus immunity

• Previous medical history

• Last meal

• Events leading to the injury

1. Road Traffic Accidents:
   • where speeds were in excess of 40 mph

   • where the victim was ejected from the vehicle

   • where other victims were killed

   • where there was severe disruption of the vehicle passenger compartment

2. A fall of greater than 10 feet (remember a patient who is six feet tall and sustains a head injury falling off a six foot wall has sustained an energy transfer to the head compatible with a total fall of twelve feet).

3. In penetrating trauma from gunshot the amount of tissue damage increases with the velocity of the bullet particularly if the bullet does not exit the body (when all of the projectile's energy is transferred to the tissues).

Head: a Glasgow Coma Scale (Table 3) score should be documented at this point .The scalp should be palpated for fractures, lacerations and other deformities. Adults rarely lose a significant amount of blood from scalp wounds but brisk bleeding should be stopped. Any injury to or around the eye should be noted. Periorbital and/or subconjunctival haemorrhage may indicate a base of skull fracture and penetrating injuries or foreign bodies are not uncommon.

Blood or cerebrospinal fluid coming from the ears or nose also indicates basal skull fracture. When blood is mixed with CSF the presence of CSF can be demonstrated by dropping the blood onto blotting paper when a double ring is formed.

Facial fractures must be sought by careful palpation, but only treated at this stage if likely to compromise airway patency. Swelling or haemorrhage associated with such fractures may cause delayed respiratory obstruction and must be anticipated. Movement of the maxilla indicates a middle third facial fracture.

Neck: the patient should be asked if they have any neck pain. With an assistant performing in-line immobilisation, the tapes, sand bags and neck collar should be gently removed and the neck examined for lacerations, swellings, tenderness or deformity of the cervical spine. Penetrating neck wounds must be explored under general anaesthesia.

A lateral X-ray of the cervical spine must show all the vertebrae including the body of the 1st thoracic vertebra. Traction downwards on the arms should help to obtain a good film. X-rays alone cannot detect all injuries to the cervical spine, and much depends on the history and examination as well as an experienced review of lateral, antero-posterior and odontoid peg radiographs.

Thorax: The entire chest must be examined for signs of injury. This includes palpating for fractures of the clavicles and ribs and the presence of subcutaneous emphysema. Percutaneous drainage of haemo-pneumothoraces must be performed when they are diagnosed or strongly suspected. Pleural drainage must also be considered in those with multiple rib fractures, particularly if undergoing positive pressure ventilation, due to the risk of developing a tension pneumothorax. Deceleration injuries may cause tracheobronchial injury, transection of the thoracic aorta, cardiac injury or diaphragmatic rupture.

Complete aortic transection is immediately fatal. Incomplete aortic transection is suggested by the history, chest X-ray signs of widening of the mediastinum, pleural capping (fluid shadow at apex of lung), and a shift of the trachea to the right and/or inferior displacement of the left main bronchus. Treatment of these injuries needs specialist facilities. Aortogram X-rays are used to diagnose aortic injuries and careful control of the blood pressure is necessary perioperatively to prevent ex -sanguination.

Cardiac contusion may be suggested by the history, inadequate response to intravenous fluids, high central venous pressure and ECG changes. Investigations include echocardiography which may show abnormal heart wall movements and/or pericardial effusions. Inotropic agents such as an adrenaline infusion may be required. Echocardiography is also useful for diagnosing heart valve rupture.

Diaphragmatic rupture is commoner on the left and is diagnosed if abdominal contents are visible in the hemithorax on a chest X-ray. However, positive pressure ventilation may have been required if respiratory failure was present, and this may reduce the hernia. If a diaphragmatic injury is suspected a naso or oro-gastric tube should be inserted and the X-ray repeated. Surgical repair is required if the injury is diagnosed. Right sided ruptures are difficult to diagnose, but a raised or irregular hemidiaphragm may suggest a defect.

(Continued...)

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