Airway patency is first evaluated by listening for vocalizations, asking the
patient to speak, and looking in the patient’s mouth for signs of obstruc-
tion. Breathing is assessed by observing for symmetric rise and fall of the
chest and listening for bilateral breath sounds over the anterior chest and
axillae. The chest should be palpated for subcutaneous air and bony crepi-
tus. Circulatory function is assessed by noting the patient’s mental status,
skin color and temperature, and pulses. The patient’s neurologic status is
assessed by noting level of consciousness and gross motor function. An ini-
tial GCS should be calculated in the ED. Lastly, the patient is completely
undressed to evaluate for otherwise hidden bruises, lacerations, impaled
foreign bodies, and open fractures. Only after the primary survey is com-
plete and life-threatening injuries are addressed, and the patient is resusci-
tated and stabilized, is the secondary head-to-toe survey undertaken.
(a)This patient will require a chest tube for presumed hemo- or pneu-
mothorax demonstrated by decreased breath sounds and oxygen saturation
of 93%. However, the airway should first be secured. (b)A DPL or FAST
examination is used to screen the abdomen for hemoperitoneum. However,
airway and breathing take priority in this patient. (c)Bilateral ED trephina-
tion (burr holes) is rarely, if ever, performed and should only be considered
in the case of severe neurological impairment and definitive neurosurgical
care is not available. (d)Extremity injuries are typically not life threatening
and are assessed after the airway, breathing, and circulation are evaluated.
143.The answer is a.(Tintinalli, pp 1566-1567.)Epidural hematomas
are the result of blood collecting in the potential space between the skull
and the dura mater. Most epidural hematomas result from blunt traumato
the temporal or temporoparietal area with an associated skull fracture and
middlemeningeal artery disruption. The classic history of an epidural
hematoma is a lucent period following immediate loss of consciousness
after significant blunt head trauma. However, this clinical pattern occurs in
a minority of cases. Most patients either never lose consciousness or never
regain consciousness after the injury. On CT scan, epidural hematomas
appear lenticular or biconvex (football shaped), typically in the temporal
region. The high-pressure arterial bleeding of an epidural hematoma can
lead to herniation within hours after injury. Therefore, early recognition and
evacuation is important to increase survival. Bilateral ED trephination (burr
holes) is rarely, if ever, performed and should only be considered if defini-
tive neurosurgical care is not available.
(b) Subdural hematomas appear as hyperdense, crescent-shaped
lesions that cross suture lines. They result from a collection of blood below
160 Emergency Medicine