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View Full Version : Neuro question: A timeline of sorts after admission to a trauma center?



Christabelle
01-13-2014, 09:13 PM
An otherwise healthy young adult male arrives at the hospital with injuries resulting from a car crash (It's an older car: no airbag, possible seat belt failure). With head, neck, and chest injuries, what would the treatment procedure be?

Best I can come up with for the purposes of the story, the patient has closed head trauma; cervical vertebrae fractures/dislocation; pneumothorax; pulmonary contusions; rib fractures; other injuries if fitting (ie. ruptured spleen, etc.?). After admission to the trauma center, do they operate or wait?

If the character is comatose and suffering from low blood oxygen as a result of lung and chest injuries, would surgery to decompress and stabilize his vertebrae be put off until his vitals improve?

Basically, this story is from he patient's 15-year old brother's perspective, so it doesn't need great detail, just accuracy as far as "he was in surgery when we got to the hospital" or if he's been in ICU for days before the surgeon can operate or whatnot. The 15-year old is bright and tuned in to what's going on with his family, and he comments a good bit on what's happening to his brother.

I hope this question made sense!

Albedo
01-15-2014, 04:46 PM
Hi Christabelle,

in a multi-trauma situation, things will be prioritised by most imminent threat to life. Prior to your patient even arriving, a call would be put forward, and people would immediately start preparing the resuscitation bay. The patient would be taken straight into the bay (clerking, etc. happens later), and a team of doctors and nurses would set to work.

Lots of things would happen simultaneously, e.g. wide-bore IV access obtained and bloods taken by juniors or nurses, while senior emergency specialists start by stabilising the patient's airway, examining the patient for signs of respiratory or cardiac compromise, screening the C-spine, looking for external injuries, and performing a FAST scan (http://en.wikipedia.org/wiki/Focused_assessment_with_sonography_for_trauma).

Of your list of injuries, tension pneumothorax is probably the most immediate threat to life, and would be detected on either the FAST scan or on a mobile chest Xray (which would be performed in the resus bay based on clinical indication). If there was suspected head trauma, or any reduced level of consciousness, an urgent head CT would be performed to look for intracranial haemorrhage. The third big threat, intraabdominal bleeding, would be detected on the FAST scan or abdominal CT.

Tension pneumothorax is treatable in the emergency department. Serious intraabdominal or intracranial bleeding would be indications for urgent surgery. Not so much a C-spine injury, unless it was grossly unstable on CT/MRI or there is frank compromise of the spinal cord. It's more likely he will be stabilised in ED then transferred to ICU with cervical spine precautions maintained, the immediate threats to life treated, and the spinal surgeon called to give phone advice, with surgical review in 24 hours or so. The patient will be given IV steroids, to reduce inflammation.



Disclaimer: I work in a hospital, but thankfully very little in ED. There are several emergency workers in these forums who might be able to provide a more accurate picture.

Christabelle
01-16-2014, 08:00 AM
Thanks for the reply, Albedo. To complicate things up a bit more, what would happen if the C-spine injury was unstable and compromising the spinal cord? Immediate surgery or postpone until inflammation and/or other dangers subside?

Los Pollos Hermanos
01-17-2014, 03:17 AM
I find Slideshare useful for medical stuff, which I can later verify with a doctor I know. Here's one about assessing patients brought into A&E/the ER with multiple trauma:

http://www.slideshare.net/monsif80/polytrauma-14206606?from_search=1

You can search for specific conditions, etc at the top of the page.

Hope it helps!

LPH.

Albedo
01-19-2014, 04:48 AM
Thanks for the reply, Albedo. To complicate things up a bit more, what would happen if the C-spine injury was unstable and compromising the spinal cord? Immediate surgery or postpone until inflammation and/or other dangers subside?

Here's an abstract (http://www.ncbi.nlm.nih.gov/pubmed/11834996) suggesting that immediate decompression surgery leads to improved outcomes. I have no neurosurgery experience; maybe someone else is more aware of current best practice.

Christabelle
01-20-2014, 07:39 PM
Here's an abstract (http://www.ncbi.nlm.nih.gov/pubmed/11834996) suggesting that immediate decompression surgery leads to improved outcomes. I have no neurosurgery experience; maybe someone else is more aware of current best practice.
Thanks for the abstract, Albedo. It certainly makes sense from my non-medical background. I'm wondering if he could realistically withstand immediate decompression with unstable vitals.

It would help my story if that surgery didn't occur immediately, or if the surgeon went back a few days later to work on something. Sorry I'm making this so confusing.

Any neuros around who could give me a quick rundown of what is doable in such a case?