MULTIPLE INJURIESSurgical Emergencies 221(iv) Infusion fluid
(a) infuse normal saline or Hartmann’s (compound sodium
lactate) to correct hypovolaemia
(b) remember that in healthy adults the only signs associated
with the loss of up to 30% of the circulatory blood volume
(1500 mL) may be tachycardia with a narrowed pulse pressure
(c) therefore, a consistent fall in systolic blood pressure indicates
that at least 30% of the blood volume has already been lost
(d) change infusion fluid to blood if 3000 mL of normal saline
or Hartmann’s (compound sodium lactate) fail to reverse
hypotension. A full cross-match takes 45 min, a type-specific
cross-match takes 10 min, and O rhesus-negative blood is
available immediately
(e) use a blood warmer and macropore blood filter for multiple
transfusions- give fresh frozen plasma 8–10 units and platelets after
transfusing 8–10 units of blood or more, i.e. in a 1:1 ratio
for a ‘massive blood transfusion’.
(v) Send blood for haemoglobin, urea and electrolytes (U&Es),
liver function tests (LFTs) and blood sugar, and cross-match at
least 4 units of blood according to the suspected injuries. Save
serum for a drug screen in case alcohol or drug intoxication is
subsequently suspected.
(vi) Cardiac tamponade
(a) consider cardiac tamponade if there is persistent hypotension
with distended neck veins that fill on inspiration (Kussmaul’s
sign), particularly following penetrating chest trauma
(b) arrange an immediate focused ultrasound to look for
pericardial fluid (blood)
(c) call the surgical and/or cardiothoracic team for an
urgent thoracotomy if there is persistent haemodynamic
compromise (see p. 237).
5 Disability: brief neurological evaluation
(i) Assess the level of consciousness using the GCS (see p. 30).
(ii) Examine the eye movements, pupil size, shape and reactivity.
(iii) Assess for abnormal tone, weakness and gross sensory loss, or
an asymmetrical response to pain if the patient is unconscious.
Check the limb reflexes, including the plantar responses.
(iv) Examine the face and scalp for injuries.
6 Exposure: completely undress the patient
(i) Request a chest radiograph (CXR), pelvic X-ray and lateral
cervical spine X-ray, known as the ‘trauma series’. Perform these
in the resuscitation bay without interrupting patient care