(b)The patient will certainly require volume resuscitation and pain
control, but airway management takes priority. (c and d)It is important
not to get distracted by other injuries in a critical patient who requires
definitive airway management as first priority. (e)Although the patient will
require a blood transfusion, the airway must be addressed first.
157.The answer is a.(Rosen, pp 329-368.)Diving injuriesmust always
be suspected in near-drowning patients. This patient presents with abdom-
inal breathing and spontaneous respirations. This pattern provides an
important clue to a cervical spine injury. The diaphragm is innervated by
the phrenic nerve, which originates from the spinal cord at the C3-C4
level, whereas the intercostal muscles of the rib cage are supplied by nerves
that originate in the thoracic spine. Therefore, abdominal breathing in the
absence of thoracic breathing indicates an injury below C4. His bradycardia
in the presence of hypotensionis suspicious for neurogenic hypotension,
which is caused by loss of vasomotor tone and lack of reflex tachycardia
from the disruption of autonomic ganglia. However, this is a diagnosis of
exclusion and should only be made once all other forms of shock are ruled
out. It is important to maintain c-spine immobilizationto prevent further
progression of an injury.
(b)Electrolyte abnormalities are typically not a concern in near-
drowning injuries. (c)Any patient with hypoxia and hypoperfusion gener-
ally also has a metabolic acidosis. Treating the underlying pathology will
also treat the acidosis.
(d)All near-drowning cases (fresh or saltwater) involve the loss of
surfactant and subsequent atelectasis with a high potential for hypoxia.
(e)Although a toxic ingestion should always be considered, there are no
specific indications for it in this patient.
158.The answer is d.(Rosen, pp 387-388.)Pulmonary contusionsusu-
ally occur after a blunt traumatic force to the chest that causes injury to the
lung parenchyma. This is followed by alveolar edema and hemorrhage.
Pulmonary contusion is reported to be present in 30% to 75% of patients
with significant blunt chest trauma, most often from automobile collisions
withrapid deceleration. It can also be caused by high-velocity missile
wounds and the high-energy shock waves of an explosion in air or water.
Pulmonary contusion is the most significant chest injury in children. Clini-
cal manifestations include dyspnea that is usually worsening, tachypnea,
cyanosis, tachycardia, hypotension, chest wall bruising, decreasing oxygen
170 Emergency Medicine