Emergency Medicine

MULTIPLE INJURIES

222 Surgical Emergencies

(a) lateral cervical spine X-rays have now largely been replaced by

incorporating the cervical spine with CT scanning of the head.

(ii) Examine the front of the abdomen, including the perineum, for

evidence of blunt or penetrating trauma, e.g. seat-belt bruising

or a tyre mark on the skin. Cover any exposed abdominal viscera

with saline-soaked packs.

(iii) Log-roll the patient and examine the back for evidence of blunt

or penetrating trauma. Palpate the spine for deformity and

widened interspinous gaps.

(iv) Perform a rectal examination to assess the anal sphincter tone,

position of the prostate, integrity of the rectal wall, and to check

for evidence of internal bleeding.

(v) Assess the pelvis by springing to detect instability from major

pelvic ring fracture, although this is an unreliable sign.

(vi) Look for associated urethral injury. Suspect urethral transection

if there is any bleeding from the urethral meatus, a scrotal

haematoma or a high-riding prostate

(a) do not attempt urethral catheterization if any of these are

present

(b) otherwise, insert a urethral catheter and measure the urine

output, which should be >50 mL/h in the adult, and

1 mL/kg per hour in a child.

7 Pass a large-bore nasogastric tube, or orogastric tube if a basal skull or

mid-face fracture is present (see p. 433).

(i) This is particularly important in children, who commonly

develop acute gastric dilatation following trauma.

8 Splint major limb fractures, cover compound injuries with sterile dressings

and check the peripheral pulses.

9 Administer increments of morphine 2.5–5 mg i.v. titrated to ana lgesic response.

The above procedures will save life during the resuscitation phase, and allow a

decision on priorities in proceeding to def initive care.

Obtain as full a history as possible from ambulance crew, witnesses or relatives, as

well as the patient. A useful mnemonic for remembering the components in the

history is AMPLE (see Table 8.2).

Table 8.2 Mnemonic for components of the history in multiple trauma

A Allergies

M Medications

P Past history, including alcohol and cigarette use

L Last meal

E Events/environment relating to the injury, including time, speed of impact,

initial vital signs, and any change in condition