MULTIPLE INJURIES220 Surgical Emergencies
2 Maintain the integrity of the cervical spine
(i) Place the unconscious head injury and the patient with suspected
neck injury in a semi-rigid collar.
(ii) Minimize head movement. When the patient requires turning,
the body should be ‘log-rolled’, holding the head in the neutral
position at all times.
3 Breathing and ventilation
Look for and treat the following critical conditions:
(i) Tension pneumothorax
(a) suspect a tension pneumothorax if examination reveals
tachycardia, hypotension, unequal chest expansion, absent or
decreased breath sounds and distended neck veins
(b) insert a wide-bore cannula into the second intercostal space
in the mid-clavicular line on the affected side. Following
initial decompression, proceed to formal intercostal tube
drainage (see p. 471).
(ii) Sucking chest wound with open pneumothorax
(a) cover with an occlusive dressing such as paraffin gauze under
an adhesive film dressing, secured along three sides only.
Leave the fourth side open for air to escape
(b) proceed to formal intercostal catheter drainage (see p. 473).
(iii) Flail chest
(a) causes paradoxical movement of part of the chest wall and
may necessitate positive-pressure ventilation
(b) an associated haemothorax or pneumothorax will require an
intercostal catheter chest drain to prevent the development
of a tension pneumothorax, if positive-pressure ventilation is
used.
4 Circulation with haemorrhage control
(i) Apply a bulky sterile dressing to compress any external bleeding
point (not a tourniquet, as this increases bleeding by venous
congestion).
(ii) Monitor the pulse, blood pressure, pulse oximetry and
electrocardiogram (ECG).
(iii) Establish an i.v. infusion
(a) insert two large-bore (14- or 16-gauge) cannulae into the
antecubital veins
(b) one cannula should be below the diaphragm in mediastinal or
neck injuries, e.g. in the femoral vein
(c) although a central venous (CVP) line is useful both
to administer fluids and to monitor the response to
resuscitation, only senior ED staff should perform this to
minimize the potential complications of arterial puncture
and pneumothorax. See page 476.