0071643192.pdf

■ Patients with C-spine fractures, ligamentous instability, or neurologic

deficits consistent with a C-spine injury should be immobilized.

■ Neurosurgical consultation is appropriate.

■ Volume and pressors may be necessary for hypotension secondary to neuro-

genic shock, but be sure to rapidly evaluate for other causes of hypoten-

sion (ie, hemorrhage).

■ While it remains controversial, high-dose methylprednisolonehas become

the standard of care in the United States for blunt (not penetrating) injury

to the spinal cord.

■ First dose must be given within 8 hours of injury.

■ 30 mg/kg IV over 15 minutes

■ 45-minute pause

■ Then 5.4 mg/kg/hour for 23 hours

■ Worsening neurologic function following spinal cord injury is usually an

indication for surgical intervention.

A 60-year-old female is brought into the ED after MVC with hypotension,

dyspnea, and tracheal deviation to the right. Lung sounds are absent over

the left chest. What should be your first step?

This patient clinically has a tension pneumothorax. Do not wait for X-ray

confirmation. Perform immediate decompression by placing a 14-g angiocatheter

in the L second intercostal space at the midclavicular line.

BLUNT CHEST TRAUMA

Simple Pneumothorax

The accumulation of air within the pleural space, most commonly a result of

trauma, though may occur spontaneously

SYMPTOMS/EXAM

■ Chest pain and shortness of breath are the most common presenting

complaints.

■ Decreased or abnormal breath sounds, hyperresonance on the ipsilateral

lung may be present

DIAGNOSIS

■ Upright CXR: Findings that suggest pneumothorax include: Absent lung

markings in the periphery of the lung field, mediastinal shift, subcutaneous

emphysema, or a low lateral diaphragm on the side of the injury (deep

sulcus sign) all suggest pneumothorax (see Figure 3.9).

■ An expiratory film may allow visualization of a small pneumothorax not

seen on initial CXR.

■ CT may pick up occult pneumothorax (one not seen on upright CXR).

TREATMENT

■ Small pneumothorax (< 1 cm from chest wall and only in upper third of chest

in adults) may be treated with 100% O 2 via NRB maskand repeat CXR.

■ Large pneumothorax should receive a chest tube (24F or smaller if no

hemothorax).

TRAUMA