You are called to see a 65 year old male tourist who has been admitted to your emergency department after being hit by a car while attempting to cross a busy street. He is unconscious and has obvious chest and limb injuries.

(b)       Please discuss the timing and nature of any investigations which you would perform.

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College Answer

Urgent early investigations include urea and electrolytes, full blood examination and blood group and cross match (done when initial venous access is obtained).   It is reasonable to also perform arterial blood gas analysis and a coagulation profile at this time.

During the resuscitation phase before the secondary survey, it is reasonable to get a lateral cervical spine, supine chest X-ray, and pelvis X-ray, as long as this can be done without moving the patient to  a  separate  area.    Some  specific  abdominal  assessment  should  be  made  as  the  patient  is unconscious (DPL, FAST or CT scan), earlier if haemodynamically unstable.  A urinary catheter (unless contraindicated) should be inserted at this time to monitor urine output, and an ECG should be obtained (± echocardiography or CVP monitoring if unsure of cardiovascular status).

More specific X-rays of suspected or high risk areas (eg. full cervical spine series, chest CT and head CT, limb and thoracic and lumbar spine X-rays) should be done when patient is haemodynamically stable and ideally before transfer to ICU or theatre (unless required urgently). Definitive exclusion of thoracic aortic injury (trans-oesophageal  echocardiography  or CT angiography) should be performed if clinically indicated when haemodynamically stable.

Repeat assessment of blood gases, Hb and coagulation may be needed early.

Intra-cranial pressure monitoring may be required depending on clinical status or CT appearance (in this 65 year old man). This is not usually urgent, but may facilitate titration of modalities to control ICP and CPP. It may be inserted in ICU or pre-operatively if prolonged time in the operating theatre is anticipated.

Discussion

This is a question about the initial blood workup and primary/secondary survey investigations.

Thus:

Bloods:

  • FBC
  • EUC
  • CMP
  • LFT
  • Coags
  • Crossmatch

Imaging

  • Chest Xray
  • FAST including pericardium
  • Pelvic Xray
  • Long bone Xrays
  • CT trauma series including aortogram

Monitoring

  • ECG
  • Urine output
  • Arterial invasive blood pressure
  • ICP monitoring may be indicated if the intracranial pressure cannot be monitored clinically

References

References

ATLS student course manual, 8th edition (Chapter 5) - American College of Surgeons Committee on Trauma