and motor responsiveness. Although the GCS was originally developed to
assess head trauma at 6 hours postinjury, it is commonly used in the acute
presentation. This patient received a score of 3 for eye opening to verbal
command, 4 for disorientation, but conversant, and 6 for obeying verbal
commands.
133.The answer is a.(Rosen, pp 415-416.)Since most people are right-
handed and hold the offending instrument in their right hand, the LUQ is
most commonly injured in stab wounds. However, the liveroccupies the
most space in the abdomen and therefore is the most common organ injured.
(b)The small bowel is the second most commonly injured organ in
stab wounds and is the most common organ injured in projectile penetrat-
ing abdominal trauma (eg, GSW). The stomach, colon, and spleen (c, d,
and e)are less commonly injured than the liver and small bowel in pene-
trating abdominal trauma.
134.The answer is d.(Rosen, pp 381-382.)Simple rib fracturesare the
most common form of significant chest injury. Ribs usually break at the
point of impact or at the posterior angle, which is structurally the weakest
area. The fourth through ninth ribs are most commonly involved. Rib frac-
tures occur more commonly in adults than in children owing to the relative
inelasticity of the adult chest wall compared to the more compliant chest
wall of children. The presence of two or more rib fractures at any level is
associated with a higher incidence of internal injuries. The treatment of
patients with simple acute rib fractures includes adequate pain relief and
maintenance of pulmonary function. Oral pain medications are usually
sufficient for young and healthy patients. Older patients may require better
analgesia with opioids, but care must be taken to avoid over sedation. Con-
tinuing daily activities and deep breathing is important to ensure ventila-
tion and prevent atelectasis. If there is a question about the patient’s ability
to cough, breathe deeply, and maintain activity, particularly if two or more
ribs are fractured, it is preferable to admit the patient to the hospital for
aggressive pulmonary care.
(a)Attempts to relieve pain by immobilization or splinting should not
be used. Although they may decrease pain, they also promote hypoventila-
tion leading to atelectasis and pneumonia. (b)A chest tube is indicated only
if a PTX or hemothorax is suspected. (c)Rib fractures heal spontaneously
and do not require surgical fixation. (e)The main concern in treating rib
fractures is preventing complications, such as atelectasis and pneumonia.
Therefore, it is important that the patient have adequate analgesia.
Trauma Answers 153