Beruflich Dokumente
Kultur Dokumente
therapy and spinal cord injury rehabilitation. The treating physician must be conversant in all of
these areas, and keep an eye on all aspects of the patients recovery if the best outcomes are to be
obtained and the worst complications avoided.
Assessment of the Polytrauma Patient
An orderly, structured assessment of the polytrauma patient has been shown to improve
care and reduce the likelihood of missed injuries. Patients with multiple injuries typically arrive
in the emergency department under the care of another health care provider, most often a trained
emergency medical technician, who will have assessed the patient in the field, established
intravenous access, and may have intubated the patient to restore or maintain the airway. They
will provide important information on the mechanism of injury, the patients condition at the
time of first contact, and evidence of neurologic function, respiratory status, and responsiveness
at the time of initial resuscitation. Their initial observations may provide important perspective
as to the patients improvement or deterioration when compared with the initial assessment in the
emergency department.
Once the patient arrives in the emergency department, resuscitation and a primary
assessment begin simultaneously. These two processes are interdependent in that the purpose of
the primary assessment is to find the causes of hemodynamic instability, respiratory impairment,
and circulatory collapse at the same time others on the team are trying to restore those functions
through volume replacement, ventilation, and pharmacologic support. Once the primary survey is
complete and the patients condition begins to stabilize, a secondary, more complete survey is
conducted, and the team can begin to formulate a plan for definitive care.
Primary Survey
Initial management of the polytrauma patient begins with an assessment of airway,
breathing, and circulation, along with neurologic status (disability) and environmental exposure.
Advanced Trauma Life Support guidelines set forth by the American College of Surgeons
advocate use of both the primary and secondary survey to provide an orderly, consistent
approach that will rapidly reveal life and limb threatening injuries.
The secondary survey consists of a head-to-toe evaluation and history. Both the primary
and secondary survey should be repeated as needed to ascertain any change in the patients
status. Initial radiographs should include those of the chest, pelvis, and cervical spine, all
obtained immediately after the primary survey is complete.
Airway
Assessment of the airway and breathing begins immediately, in the field. The patient must be
making an effort to breath, be successfully moving air, and be adequately transferring oxygen to
the circulating blood. Evaluation of effort, chest wall excursion, and breath sounds should be
done immediately on arrival. The physician should look for cyanosis and obtain an arterial blood
gas sample. Mechanical obstruction should be addressed immediately, looking for loose teeth,
dentures, blood, food, or vomitus, and intubation performed as necessary. The arterial blood gas
will assess degree of oxygenation. If oxygenation is inadequate, pulmonary function, including
tension pneumothorax, hemothorax, and flail chest, should be reinvestigated.
Breathing: Thoracic Injuries
Signs of major thoracic injury during the primary survey, including tension
pneumothorax, open pneumothorax, flail chest, massive hemothorax, and cardiac tamponade
(discussed in the following section) should be noted. Tension pneumothorax develops as air leaks
into the chest cavity either through the chest wall or from the lung. The air enters via a one-way
valve mechanism and does not exit the cavity. The affected lung collapses and as air continues
to build up, the mediastinum is displaced to the contralateral side, impeding venous return and
compressing the uninjured lung. The diagnosis is made on the clinical findings of absent breath
sounds and a hyperresonant percussion note. A chest radiograph is not required before treatment
is initiated. Treatment consists of immediate decompression by insertion of a large bore needle
into the second intercostal space in the midclavicular line of the affected side, followed by chest
tube placement.
Open pneumothorax results from large defects in the chest wall. Air will preferentially
enter the chest cavity through the defect rather than the trachea when the diaphragm contracts.
Initial management includes placement of an occlusive dressing covering the wound edges, taped
on three sides, allowing the dressing to occlude the wound with each inhalation and allowing for
air to escape during exhalation. A chest tube should be inserted at a site away from the wound as
soon as possible.
Flail chest occurs in the presence of multiple rib fractures and is usually associated with
an underlying pulmonary contusion. The flail chest segment demonstrates paradoxical chest wall
motion with inspiration and expiration, impairing ventilation. The paradoxical motion is not
solely responsible for the associated hypoxia. Pain results in restricted chest wall motion, and
pulmonary contusion contributes significantly to development of hypoxia. Intubation and
ventilation may be
necessary if hypoxia is progressive and unresponsive to initial measures.
Massive hemothorax, the rapid accumulation of at least 1,500 mL of blood in the chest,
may be the result of blunt or penetrating trauma. The blood loss may contribute to hypoxia, and
initial management includes both restoration of blood volume and decompression of the chest
cavity by chest tube placement. Massive hemothorax often requires thoracotomy to control the
source of hemorrhage.
Circulation
Evaluation of circulation involves physical examination and an assessment of vital signs
including blood pressure and heart rate. Intravenous fluid infusion is recommended in all
patients, and is usually started before reaching the hospital. Resuscitation should be monitored
by blood pressure, heart rate, perfusion, and urine output. If the extremities are cold, clammy,
and/or cyanotic, the patient should be treated for hypovolemia irrespective of pulse or pressure.
If brisk bleeding from an extremity or penetrating wound is encountered, direct pressure should
be applied immediately.
Goals for urine output are 0.5 mL/kg/h in adults and 1.0 mL/kg/h in children. Central
venous pressure will provide information regarding atrial-filling pressures. Elderly patients with
severe thoracic trauma require a pulmonary artery catheter. The arterial-alveolar gradient should
be calculated to detect ventilation-perfusion mismatches. Crystalloid infusion is used in the
initial management of these patients, through large bore intravenous access. If intravenous access
is not readily available, cutdown on the saphenous, femoral, or cubital veins may be necessary.
For patients who are experiencing exsanguination, immediate use of universal donor blood group
6 to 8 days).
Acute Care
In the acute period, the primary survey and secondary
assessment and hemodynamic resuscitation are accomplished.
Head, chest, abdomen, and pelvic injury are all
recognized and life-saving/limb-saving interventions are
initiated. Significant epidural and subdural bleeding requires
immediate evacuation. Once a hemothorax is diagnosed,
a chest tube drainage should be placed. If
more than 1,500 mL of blood is obtained through the
chest tube or if drainage of more than 200 mL/h for 2 to
4 hours occurs, surgery should be considered. Continued
hemorrhage into the peritoneal cavity of a hemodynamically
unstable patient requires emergent laparotomy.
Bleeding from the pelvic region must be ruled out before
laparotomy is done.
External immobilization must be performed if the
pelvic ring is determined to be unstable. Initial external
immobilization consists of sandbags and straps, beanbags,
or military antishock trousers. The use of military
antishock trousers, however, has been associated with
compartment syndrome and decreased respiratory ability.
In the emergency department, external immobilization
has been shown to decrease blood loss and to lower