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trauma surgery: #2: Initial Assessment and Management [精华]

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BoYang1998

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let's push this case a little bit further.

say this patient didn't respond to the IVF resuscitation, BP dropped to 70/40. you take him to the OR. on the table, his BP dropped to 0/0, heart arrested. what would you do ?

2007-03-19 09:36

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• 一图解读｜血常规化验单

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BoYang1998

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Continue secondary survey:

Physical Examination

1. Head (See Chapter 6, Head Trauma)
Hie secondary survey begins with evaluating the head and identifying all related neurologic and significant injuries. the eyes should be reevaluated for
a. Visual acuity
b Pupillary size
c. Hemorrhages of the conjunctiva and fundi
d. Penetrating injury
e. Contact lenses (remove before edema oc-cnrs)
f Dislocation of the lens §. Ocular entrapment

2. Maxillofacial

Maxillofacial trauma, not associated with airway obstruction or major bleeding, should be treated only after the patient is stabilized completely and life-threatening injuries have been managed.

2007-03-19 09:45

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• 中级证为什么不能全国通用，那考了还有什么用

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BoYang1998

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3. Cervical spine and neck --------very important

Patients with maxillofacial or head trauma should be presumed to have an unstable cervical spine injury (fracture and/or ligamentous injury), and the neck should be immobilized until all aspects of the cervical spine have been adequately studied and an injury has been excluded. The absence of neurologic deficit does not exclude injury to the cervical spine, and such injury should be presumed until a complete cervical spine radiographic series is reviewed by a doctor experienced in detecting cervical spine fractures radiographically.

Examination of the neck includes inspection, palpatian, and auscultation. Cervical spine tenderness, subcutaneous emphysema, tracheal deviation, and laryngeal fracture may be discovered on a detailed examination. The carotid arteries should be palpated and auscultated for bruits. Evidence of blunt injury over these vessels should be noted and, if present, should arouse a high index of suspicion for carotid artery injury. Occlusion or dissection of the carotid artery may occur late in the injury process without antecedent signs or symptoms. Angiography or duplex ultrasonography may be required to exclude the possibility of major cervical vascular injury when the mechanism of injury suggests this possibility. Most major cervical vascular injuries are the result of penetrating injury. However, blunt force to the neck or a traction injury from a shoulder-harness restraint can result in intimal disruption, dissection, and thrombosis.

Protection of a potentially unstable cervical spine injury is imperative for patients wearing any type of protective helmet. Extreme care must be taken when removing the helmet.

Penetrating injuries to the neck have the potential of injuring several organ systems. Wounds that extend through the platysma should not be explored manually or probed with instruments in the emergency department, or by individuals in the emergency department who are not trained to deal with such injuries. The emergency department usually is not equipped to deal with problems that may be encountered unexpectedly. These injuries require evaluation by a surgeon either operatively or with specialized diagnostic procedures under direct supervision by the surgeon. The finding of active arterial bleeding, an expanding hematoma, arterial bruit, or airway compromise usually requires surgical operative evaluation. Unexplained or isolated paralysis of an upper extremity should raise the suspicion signs of a cervical nerve root injury and be accurately documented.

2007-03-19 09:46

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• 被曝欠外债20亿、欠薪1年多，全院医护第2次游行讨薪！

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BoYang1998

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4. Chest

Visual evaluation of the chest, both anterior and posterior, identifies such conditions as open pneu-mothorax and large flail segments. A complete evaluation of the chest wall requires palpation of the entire chest cage, including the clavicle, ribs, and sternum. Sternal pressure may be painful if the sternum is fractured or costochondral separations exist. Contusions and hematomas of the chest wall should alert the doctor to the possibility of occult injury.

Significant chest injury may be manifested by pain, dyspnea, or hypoxia. Evaluation includes auscultation of the chest and a chest x-ray. Breath sounds are auscultated high on the anterior chest wall for pneumothorax and at the posterior bases for hemothorax. Auscultatory findings may be difficult to evaluate in a noisy environment, but may be extremely helpful. Distant heart sounds and narrow pulse pressure may indicate cardiac tamponade. Cardiac tamponade or tension pneumothorax may be suggested by the presence of distended neck veins, although associated hypo-volemia may minimize this finding or eliminate it altogether. Decreased breath sounds, hyperreso-nance to percussion, and shock may be the only indications of tension pneumothorax and the need for immediate chest decompression.

The chest x-ray confirms the presence of a hemothorax or simple pneumothorax. Rib fractures may be present, but they may not be visible on the x-ray. A widened mediastinum or other ra-diographic signs may suggest an aortic rupture ---

BOLUS QUESTION: what would you do if you see a widen mediatinum on the CXR?.

2007-03-19 09:50

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• 综合医院全科门诊中乏力患者特征及就诊原因分析

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