TRIPASS XR تري باس

 

glucose, electrolytes, AED levels, ABG, tox screen

Figure 83·3. Guidelines for management in status epilepticus. ABG, arterial blood gases; AED, antiepileptic drug;

CBC, complete blood count; PE, phenytoin equivalent. Reprinted with permission from Lung DO, Catlett CL, Tintinalli JE.

Chapter 1 65. Seizures and Status Epilepticus in Adults. In: Tintinalli JE, Stapczynski JS, Cline OM, Ma OJ, Cydulka RK,

Meckler GO, eds. Tintinalli's Emergency Medicine: A Comprehensive Study Guide. 7th ed. New York: McGraw-Hill,

201 1 .

..... Discharge

Patients with first-time resolved seizures may be safely discharged home if no secondary cause of the seizure is identi ­

fied and the patient has returned to normal mental status.

Antiepileptic drugs are not indicated initially, as only one

third of these patients will have a second seizure over their

lifetimes. The patient should have an outpatient work-up

with a neurologist including an EEG and MRI. I nstruct the

patient to avoid driving vehicles, swimming, or participating

in any other activity that may put themselves or anyone else

in danger if a second seizure occurs. Patients with a known

seizure disorder may be discharged if there are no compli ­

eating factors after their antiepileptic drug levels are r epleted.

SUGGESTED READING

Duvivier E, Pollack C. Seizures. In: Marx J A. Rosen's Emergency

Medicine. 7th ed. Philadelphia, PA: Elsevier, 2009. Chapter 100,

1 346-1355

Lung D, Catlett C, Tintinalli J. Seizures and status epilepticus in

adults. In: Tintinalli JE, Stapczynski JS, Cline DM, Ma OJ,

Cydulka RK, Meckler GD. Tintinalli's Emergency Medicine: A

Comprehensive Study Guide. 7th ed. New York, NY: McGrawHill, 20 1 1, pp. 1 1 53-1 1 59.

Tarabar A, Ulrich A, D'Onofrio G. Chapter 99 Seizures. In Adams

J, Barton E, Collings J, DeBlieux P, Gisondi M, Nadal E.

Emergency Medicine: Clinical Essentials. 2nd ed. Philadelphia,

PA Saunders, 2013, pp. 857-69.

Trauma Principles

jorge Fernandez, MD

Neil Rifenbark, MD

Key Points

• Assess all trauma patients with a rapid primary

survey followed by a more comprehensive secondary

eval uation.

• Address all emergent life threats in a stepwise manner

during the primary survey before progressing to the

next stage.

INTRODUCTION

Trauma is currently the fourth leading cause of death in

the United States across all age groups and the leading

cause of death in patients under the age of 44 years. It is

responsible for more deaths in patients under the age of

19 years than all other causes combined. Approximately

40% of all emergency department (ED) visits are for

trauma-related complaints, and the annual costs exceed

$400 billion. Adding to these costs, permanent disability is

actually 3 times more likely than death in this cohort.

Trauma is broadly classified by mechanism into blunt

and penetrating varieties, with the former more than

twice as common as the latter. Regardless of mechanism,

victims of significant trauma present with a wide range

of complex problems, and their proper care necessitates

a multidisciplinary approach, including emergency physicians,

trawna surgeons, and the appropriate subspecialties. Most

trawna care delivery systems follow the Advanced Trawna

Life Support guidelines developed and maintained by the

American College of Surgeons.

The mortality rates for trawnatic injuries typically

follow a trimodal distribution. Certain injury patterns

including major vascular injuries and high cervical cord

disruption with secondary apnea result in near immediate

death. The second cohort of injuries, including conditions

• Treat hemodynamically unsta ble patients as hemorrhagic shock until proven otherwise.

• Initiate aggressive volume resuscitation in all unstable

patients while concurrently searching for active sources

of hemorrhage.

such as pnewnothorax and pericardia! tamponade, typically

evolve over a duration of minutes to hours and are generally

responsive to aggressive emergent intervention. Septicemia and

multisystem organ failure account for the third peak of fatalities

and typically occur weeks to months after injury.

CLINICAL PRESENTATION

� History

Attempt to identify the severity of mechanism, as this will

predict the patterns of injury. For example, determine the

approximate speed of a motor vehicle collision (MVC) and

whether or not the patient was restrained. Emergency

medical service personnel can be an invaluable resource,

especially in amnestic and nonverbal patients. In assault

patients, inquire if they can recall exactly what they were

struck with and the nwnber of times. Ask if there was any

loss of consciousness, as this may portend to a significant

head injury. For penetrating trawna, ask about the number

of shots heard and how many times the patient felt himself

or herself get shot.

Obtain a brief medical history using the AMPLE

mnemonic. Ask about any known drug allergies, current

medication use, past medical history, last oral intake, and

the immediate events leading up to the injury. Keep in

358

TRAUMA PRINCIPLES

mind that regardless of past history, elderly patients have

less physiologic reserve and are prone to higher rates of

morbidity and mortality. In females of childbearing age,

always ask about the last menstrual period and assume that

they are pregnant until proven otherwise. Pregnant patients

are at higher risk for domestic violence and warrant

unique considerations such as placental abruption,

uterine rupture, the supine hypotensive syndrome, and

fetal distress or demise. Even apparently minor injuries

including falls and low-speed motor vehicle accidents can

induce preterm labor or placental abruption.

Always ask about any evolving symptoms and identify

the exact locations of pain, as this will guide your physical

exam. Patients with altered mental status should be

treated as having a traumatic brain injury until proven

otherwise. Shortness of breath may indicate an underlying

pneumothorax (PTX), pulmonary contusion, or pericardia!

tamponade. Chest pain may indicate an underlying fracture

of the ribs or sternum, hemothorax (HTX), or traumatic

aortic injury (TAl). Assume that patients with abdominal

pain, hematemesis, or rectal bleeding have an intra-abdominal

visceral injury until proven otherwise. Patients complaining of hematuria should be considered at a high risk for

injury to the genitourinary (GU) tract. Neurologic complaints including weakness and paresthesias may indicate

an underlying spinal cord injury or vascular dissection.

� Physical Examination

The physical exam in major trauma patients is very systematic

and can be divided into primary and secondary surveys.

Primary Survey

The primary survey is a very brief and focused exam meant

to identify and address emergent life threats. It should proceed in a stepwise approach outlined by the ABCDE mnemonic. Always treat any encountered abnormalities before

proceeding to the next step in the survey. If a patient decompensates at any point during his or her clinical course, return

to the beginning of the primary survey and reassess. Assume

an unstable cervical spine injury in all major t rauma victims

until proven otherwise and immediately immobilize on

presentation.

Assess the airway for patency. Signs of potential airway

compromise include pooling pharyngeal secretions, intraoral

foreign bodies, stridulous or gurgling respirations, obvious

oropharyngeal burns, significant midface, mandibular, and

laryngeal fractures, and expanding neck hematomas.

Evaluate the patient's breathing and ventilation. Expose

the chest and look for any signs of asymmetrical or

paradoxical chest wall movement, obvious deformities or

open wounds, tracheal deviation, and jugular venous

distention. Auscultate the chest to confirm strong symmetric

bilateral breath sounds. The goal is to identify the presence

of emergent life threats including tension PTX, massive

HTX, open PTX (sucking chest wound), and flail c hest.

Rapidly assess the patient's circulation by evaluating for

signs of altered mental status. A depressed level of

consciousness should be considered hypovolemic shock

until proven otherwise. Other findings concerning for hemorrhagic shock include pale, cool, and mottled extremities

and thready peripheral pulses. Auscultate the heart to detect

distant heart tones suggestive of an underlying pericardia!

effusion. Identify all sources of active bleeding and control

with the application of direct pressure.

Perform a rapid neurologic exam, noting any evidence

of disability or deficits. Document the patient's level of

consciousness; note the size, symmetry, and reactivity of

the pupils; and assess for any focal numbness or weakness.

Perform a rectal exam to ensure adequate rectal tone and

determine the patient's Glasgow Coma Scale (GCS).

Completely expose the patient to ensure that all

potential life threats have been accounted for. Carefully

log-roll the patient to examine the back and rule out any

occult penetrating injuries. Once complete, immediately

cover the patient with warm blankets to prevent the

development of hypothermia.

Secondary Survey

The secondary survey is a complete head-to-toe examination

that should be performed once the patient has been stabilized. Examine the scalp, noting any lacerations, c ontusions,

and deformities. Check the visual acuity, visual fields, extraocular movements, and pupil size and reactivity. Assess the

globe for penetrating injuries, lacerations, or proptosis.

Examine the mid-face, looking for evidence of fracture,

lacerations, epistaxis, or septal hematomas. Look for signs

of basilar skull fracture such as hemotympanum, periorbital (raccoon eyes) or retroauricular ecchymoses (Battle

sign), and cerebrospinal fluid (CSF) rhinorrhea or otorrhea. CSF rhinorrhea can be detected with the use of a

bedside "halo-test." Check for dental injuries or evidence of

mandibular fracture, including point tenderness, malocclusion, and sublingual hematomas.

Inspect the neck, noting any signs of obvious tracheal

deviation, laryngeal fracture, subcutaneous emphysema, or

expanding hematoma. Carefully palpate the cervical spine

to detect any point tenderness or bony step-offs. Re-inspect

the chest, noting any signs of contusions, asymmetry,

paradoxical movement, or penetrating injury. Palpate the

ribs and sternum, checking for point tenderness, soft tissue

crepitus, and bony deformity. Repeat auscultation of the

lungs and heart and document any abnormalities. Inspect

the abdomen for any signs of distention, contusions, or

penetrating injury. Palpate all 4 quadrants to elicit any

tenderness, guarding, or rebound. Carefully assess the pelvis

for signs of an unstable fracture by gently compressing the

iliac crests.