Concomitant Injuries

Head Injuries

The diagnosis and initial management of head injuries take priority in the earliest phase of treatment.
Mortality rates in trauma patients are associated with severe head injury more than any other organ system.
Neurologic assessment is accomplished by the use of the Glasgow Coma Scale (see earlier discussion).
Intracranial pressure monitoring may be necessary.

Evaluation

Emergency CT scan without intravenous contrast is indicated to characterize the injury radiographically after initial neurologic assessment if indicated: http://www.itim.nsw.gov.au/images/2/2b/Head_injury_CPG_full_report.pdf

Cerebral contusion
- Diagnosis: history of prolonged unconsciousness with focal neurologic signs
- Treatment: close observation
Epidural hemorrhage (tear of middle meningeal artery)
- Diagnosis: loss of consciousness with intervening lucid interval, followed by severe loss of consciousness
- Treatment: surgical decompression
Subdural hemorrhage (tear of subdural veins)
- Diagnosis: Neurologic signs may be slow to appear. Lucid intervals may be accompanied by progressive depressed level of consciousness.
- Treatment: surgical decompression
Subarachnoid hemorrhage (continuous with cerebrospinal fluid)
- Diagnosis: signs of meningeal irritation
- Treatment: close observation

Thoracic Injuries

These may result from blunt (e.g., crush), penetrating (e.g., gunshot), or deceleration (e.g., motor vehicle accident) mechanisms.
Injuries may include disruption of great vessels, aortic dissection, sternal fracture, and cardiac or pulmonary contusions, among others.
A high index of suspicion for thoracic injuries must accompany scapular fractures.
Emergency thoracotomy may be indicated for severe hemodynamic instability.
Chest tube placement may be indicated for hemothorax or pneumothorax.

Evaluation

AP chest radiograph may reveal mediastinal widening, hemothorax, pneumothorax, or musculoskeletal injuries.
CT with intravenous contrast is indicated with suspected thoracic injuries and may demonstrate thoracic vertebral injuries.

Abdominal Injuries

These may accompany blunt or penetrating trauma.

Evaluation

CT scan with oral and intravenous contrast may be used to diagnose intra-abdominal or intrapelvic injury. Pelvic fractures, lumbosacral fractures, or hip disorders may be observed.
Diagnostic peritoneal lavage has been the gold standard for immediate diagnosis of operable intra-abdominal injury. Usually, it is reserved for situations in which the patient is too unstable for the CT scanner.
Positive peritoneal lavage
- Gross blood, bile, or fecal material
- >100,000 red blood cells per milliliter
- >500 white blood cells per milliliter
Ultrasound (FAST) has been increasingly used to evaluate fluid present in the abdominal and chest cavities; a rapid, noninvasive, bedside, repeatable method to document fluid in the pericardial sac, hepatorenal fossa, splenorenal fossa, and pelvis or pouch of Douglas

Fifteen percent of abdominal trauma results in genitourinary injury.

Evaluation

If genitourinary injury is suspected (e.g., blood seen at the urethral meatus), a retrograde urethrogram should be performed before indwelling bladder catheter insertion. Urethral injury may necessitate placement of a suprapubic catheter. If a pelvic fracture is present, communication with the urologist is mandatory.
If hematuria is present, a voiding urethrogram, cystogram, and intravenous pyelogram are indicated.

Compartment Syndrome

Evaluation

It presents as pain out of proportion, tense extremity swelling, numbness or paresthesias, and painful passive muscle stretch.

Fat Embolism Syndrome

This occurs when fat globules leak into the blood system and accumulate to a point where they block blood flow. They result more often after fractures of the long bones of the lower extremity. Fat embolism syndrome can eventually cause organ damage, inflammation, and nerve damage.

Evaluation

This condition presents with anemia, fever, tachypnea, obtunded reflexes, mental confusion, coma, and petechial rash.