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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5230_Библиотеки_им_академика_М_И_Перельмана.pdf
463NECKINJURY
Fig.7.2 NICE neck injury guidance; selecting people 6 and over for imaging of
the cervical spine. National Clinical Guideline Centre (204) Head Injury:assessment
and early management. NICE Guideline 232. Copyright © NCGC. Reproduced by
permission. NICE guidance available at Mguidance.nice.org.uk/ ng232
Children under6years
Separate guidelines exist for use in children:Mguidance.nice.org.uk/ NG232
464 CHAPTER7 Emergency department
Falls and collapse
2Worrying features idHR, dBP, chest pain, palpitations, head injury
(and the associated worrying features E p. 461), long time spent on
hard surface (risk of rhabdomyolysis), hypothermia, fractures.
Think about 2Serious MI, dysrhythmias, shock, sepsis, CVA, seizure,
hypoglycaemia, hypoxia,PE;
fall (Boxes 7.5– 7.7), syncope (reex, cardiogenic, or due to orthostatic hypotension (OH)), ataxia.
It’s easy to simply focus on the consequences of the fall (eg injuries), yet
it is often the aetiology of the fall which can be more serious. If the patient cannot remember, witness accounts can be invaluable.
Syncope
$ Syncope is transient LOC due to sudden cerebral hypoperfusion of rapid
onset, short duration, and spontaneous complete recovery. It is characterized
as reex, cardiogenic, or due to OH.
2Worrying features Chest pain, breathlessness, abdominal pain, head-
ache, palpitations, onset during exertion or while supine, known HF or MI,
FH of sudden cardiac death, hypotension, bradycardia, new murmur, GI
bleed, abnormal ECG.
Ask aboutDetermine whether this was a true transient LOC. If so, is the
episode consistent with syncope or is there another cause of the LOC?
Prodrome involving fear, pallor, nausea, and/or sweating suggests reex
syncope (E p. 274). Were there any specic recognized triggers such
as micturition, carotid sinus pressure, or cough? Was there preceding
chest pain or palpitations suggesting cardiogenic syncope? Did the episode occur immediately after standing suggesting OH?
Look forPostural drop in BP, pulse rate and rhythm, heart murmurs, focal
neurological dysfunction.
Investigations In low-risk patients, ECG is sucient. Echocardiogram is
indicated if there is known structural heart disease, abnormal ECG, or
suspected cardiogenic cause. Tilt-testing may help identify reex syncope
or syncope due to OH. Ambulatory ECG monitoring can be considered
in this with frequent syncope
ManagementIn reex/OH, education, reassurance, and trigger avoidance
are usually sucient. Treat any underlying cardiogenic cause. Some diagnoses with risk of sudden cardiac death may necessitate ICD therapy.
CommonPostural hypotension, ‘mechanical’
I Box 7.5 Some precipitants offalls toconsider
SeizuresEpp. 361–3 HypoglycaemiaEp. 337
Focal neurologyEpp. 355–7 SepsisEp. 487
GCS + confusionEp. 355 Chest painEpp. 255–61
Head injuriesEp. 460 TachyarrhythmiasEpp. 264–69
Postural dropEp. 477 BradyarrhythmiasEpp. 272–5
Vertigo E p. 375 HypoxiaEpp. 285–97
Ataxia E p. 375
K Box 7.6 The elderly, recurrent falls, and
the‘mechanical’label
We all trip over things from time to time, but it’s a pretty rare occurrence, so
think again before you ascribe the lazy label of ‘mechanical’ fall to the elderly
lady lying on the trolley in front of you. Age, dementia, and other processes
of nature may well be irreversible, but the challenge is to identify and deal
with the reversible, before the next fall leads to a fractured femur and inexorable decline. Consider delirium (E pp.382–3), peripheral neuropathy
(E p. 357), untreated Parkinsonism (E p. 364), poorly controlled arthritis (E p. 512), cerebellar disease/ ataxia (E p. 375), or alcohol excess.
dvitamin D is common in the elderly and leads to dmuscle tone and bone
frailty— check plasma levels and consider oral supplementation (eg Adcal-
®
2 tabs/ 24h PO). Are diuretics and urge incontinence forcing the patient
D
3
to rush for a bathroom (E p. 399)? Does the patient have and correctly use
appropriate walking aids (sticks, frames) and is the home environment safe
(liaise with OT)? Has poor vision been assessed and corrected as much as
possible (bi/ varifocal lenses are associated with ifalls risk)? Even if you are
still unable to identify anything reversible, always assess for osteoporosis and
consider treatment (Ep. 459).
T Box 7.7 Please review this patient who has fallen
$ You will frequently be asked to assess patients who have fallen, usually as you near
the end of a long night shift. Try to safely but speedily exclude serious causes of falls
(E pp. 464–5) and post- fall injuries (particularly head andhip).
If you are bleeped, ask the nurse for a
tural BP (if possible), neuro obs, and ECG before you arrive. Establish circumstances of fall and the patient’s symptoms, specically chest pain, palpitations,
head injury, LOC, vomiting, and confusion. Document whether it was witnessed.
Review the notes to establish the patient’s baseline; is the confusion new orold?
Ask about Symptoms and activity before falling (aura, dizziness, chest pain, pal-
pitations), speed of onset, visual changes, LOC (can you remember: falling,
being on the oor, getting up?), incontinence, recovery, head injury, other injuries, mechanism of injury, length of time spent immobile;
(and investigations), heart problems, DM, Parkinsonism;
antihypertensives, antiepileptics, hypoglycaemics, diuretics, nitrates;
mobility and aids, ability to eat and drink independently, alcohol (not impossible
for in-patients!).
Examination A brief cardiovascular and neurological examination is essential.
Look over the head for signs of injury, feel for midline C- spine tenderness, and
check for reduced movement or pain in the shoulders, elbows, wrists, hips,
knees, and ankles. Ensure that patient is back to their normal mobility.
Investigations A full set of obs and ECG. Perform an abbreviated mental test
(E p. 383) to assess orientation and compare it to baseline, could it be acute- onchronic confusion? Document this. Dysrhythmia or MI (±cardiac monitor);
E pp. 382–3. Investigate for injuries as appropriate:
sistent dGCS, or head injury (Ep. 460);
E pp. 456–9 for management of trauma and E p. 460 for head injury.
ReviewIf you suspect head injury, ask the nurses to record hourly neuro obs for
eg 4h and bleep you if dGCS or concerned. Not every nurse feels comfortable
with neuro obs, check their understanding before you leave theward.
DocumentDocument your ndings; ask nurses to ll out an incident form (Ep. 34).
full set of obs including blood glucose, pos-
PMH Previous falls
DH Anticoagulants,
SH Usual
X- rayIf clinical suspicion of a fracture.
CTIf focal neurology, per-
blds
465FALLS AND COLLAPSE
466 CHAPTER7 Emergency department
2Acutely painful limb emergency
2 Airway
2 Breathing
2 Circulation
Check airway is patent; consider manoeuvres/ adjuncts
If no respiratory eort— CALL ARREST TEAM
If no palpable pulse— CALL ARREST TEAM
3Call for senior help early if patient deteriorating.
•
Sit patient up, unless pain will notallow
•
5L/ min O
•
Monitor O
•
• Brief
•
•
•
Examine patient:condensed RS, CVS, and abdoexam
•
Examine all limbs:vascular, neuro, and jointexams:
•
•
•
Venous access, take bloods:
•
if ischaemia suspected
2
sats, HR, BP,temp:
2
is the patient shocked or febrile?
history/ check notes/ ask wardsta:
arterial/ cardiac problemsorDM
recent trauma/ surgery
is the pain localized to a joint or specicarea?
check distal sensation, pulses, and cap rell (ischaemia?)
FBC, ESR, U+E, CRP, ±cardiac markers, ±sickle cell, D- dimer,
clotting,G+S
•
ABG if systemicallyunwell
• Check pulses with
•
ECG to exclude acuteMI,AF
Doppler if available
• Analgesia, eg IV morphine titrated topain
•
Consider serious causes (Box 7.8) and treat if present:
•
acute ischaemia 5L/ min O
request heparin infusion
•
compartment syndrome 5L/ min O
orthopaedics, consider fasciotomy
•
septic arthritis 5L/ min O
for urgent analysis, IV antibiotics, orthopaedics
•
necrotizing fasciitis 5L/ min O
microbiology advice), surgeons
•
gangrene 5L/ min O
•
Reassess, starting with A, B, C...
, analgesia, vascular surgeons may
2
, remove plaster,
2
, joint aspiration and phone lab to ask
2
, uids, IV antibiotics (seek
2
uids, IV antibiotics, surgeons
2,
2Box 7.8 Life- and limb- threateningcauses
Acute ischaemiaEp. 469
Compartment syndromeEp. 469
Myocardial infarction (arm)Ep. 258
Spinal cord compression E p. 369
Septic arthritisEp. 513
Necrotizing fasciitisEp. 435
GangreneEp. 469
Sickle- cell crisis E p. 49
Acute limbpain
2Worrying features (E p. 466) Sudden onset, severe pain,
dsensation, dpower, absent distal pulses, cold to touch; shock, pyr-
exia, recent surgery/ trauma.
(E pp. 510–15 for causes of acute jointpain.)
Think about 2Serious Acute ischaemia, septic arthritis, compartment
syndrome, gangrene, necrotizing fasciitis;
pain, DVT, cellulitis, thrombophlebitis, sciatica;
cyst, vasculitides, myositis, peripheral neuropathy. See Table7.3 and septic
arthritis Ep. 513.
Ask about Location, trauma, speed of onset, change on moving and
raising, back pain, chest pain, SOB;
pain, DM, MI, CVA, DVT,PE;
DHAnticoagulants; SHExercise tolerance.
Look forVascular assessmentColour, mottling, hot/ cold, cap rell, pulses
(compare both sides);
Orthopaedic assessment Evidence of trauma, swelling (distal, joint, calf ),
Neurological assessmentPower, sensation, reexes;
range of movement (active and passive), muscle, joint, or bone tenderness
(E pp. 44–51 for specic joint examinations);
SOB or you suspectDVT.
Investigations Most limb pain can be diagnosed from clinical examin-
ation; consider the following investigations:
D- dimer, venous lactate, blood cultures;
ECG AF is a thromboembolismrisk; X- rays For joint disease or bone
fractures;
ABGIf hypoxic and you suspect PE/ DVT.
ManagementEnsure adequate analgesia (E pp. 92–95). Try to deter-
mine what structure is causing the pain (eg skin, muscle, joint, bone); if
there is nothing obvious, consider arterial problems, infection, orDVT.
Treat serious underlying causes promptly (E pp. 468–9).
Supercial thrombophlebitis
$ Inammation and thrombosis of a vein, which can progress to D VT.
SymptomsGradual onset of tenderness over avein.
Signs Red, tender area with hard palpable vein/ varicosity.
Risk factorsIV cannula, varicose veins, IVDU, DVT risk factors (Ep. 508).
Investigations No specic investigations but have a low threshold for
blood and Doppler studies to exclude underlyingDVT.
Treatment Resite/ remove IV cannula, elevation, exercise, compression,
analgesia (avoid NSAIDs if elderly); if DVT suspected startLMWH.
Complications Post- phlebitic pain; if thrombophlebitis recurs or aects
other sites (migratory) suspect malignancy or vasculitis.
Musclepain
Causes Trauma, strains, bromyalgia, infection, rhabdomyolysis, drugs
(statins, ACEi, steroids), inammation (polymyalgia rheumatica, polymyositis, dermatomyositis, SLE), metabolic (dCa
endocrine (hypo/ hyperthyroid, Cushing’s), referred joint pain (Box7.9).
InvestigationsOften none; FBC, U+E, Ca
TreatmentTreat the cause, consider physiotherapy referral for rehabilitation.
Common Muscular, joint, or bone
OtherOsteomyelitis, Baker’s
PMH Recent surgery, previous limb
Respiratory assessmentIf
blds FBC, U+E, ESR, CRP,
DopplerFor pulses (?ischaemia);
2+
, dK+, dNa+, alkalosis),
2+
, CK, ESR, CRP,X- ray.
467ACUTE LIMB PAINACUTE LIMB PAIN
468 CHAPTER7 Emergency department
Table7.3 Common causes oflimbpain
Acute
ischaemia
Infection (eg
cellulitis)
DVT Gradual onset,
Compartment
syndrome
Joint Trauma, pain on
Muscle Trauma, pain on
History Examination Investigations
Rapid onset, distal
>proximal, painful
(worse with legs raised)
Gradual onset, feels
unwell, history of
trauma or bite
painful (improved
with legs raised)
Recent trauma or
surgery ±POP
movement, unable
to bear load
movement
Pulseless, cap rell
>2s, pale, cold, weak,
reduced sensation (E
p. 469)
Pyrexia; red, tender,
warm, swollen
Red, swollen, hot,
tender leg
Severe pain on
passive movement
Tender over joint,
joint eusion, pain
on movement
(active=passive)
Tender ±swelling
on muscle/ tendon
insertion, pain on
movement (active
>passive)
Doppler pulse d or
absent; obstruction
on angiography
iWCC, iCRP,
iESR, often
iD- dimer
Use Wells score
(E p. 508). iDdimer; thrombosis
on Doppler USS
Increased
compartment
pressure
Abnormal Xray (eg arthritic
changes); abnormal
synovial uid
Normal X- rays, may
have a iCK
I Box 7.9 Causes oflimb pain covered elsewhere
UlcersEpp. 446–7
Back pain/ sciaticaEpp. 368–9
CellulitisEpp. 434–5
Chronic limb painEp. 506
DVT E p. 508
SwellingEpp. 507–9
Joint painEpp. 510–15
Rashes E pp. 433–41
Necrotizing fasciitisEp. 435
Trauma E pp. 456–59
2Osteomyelitis(E OHCS11p. 502.)
Risk factorsDM, immunocompromise, open fractures, prostheses.
SymptomsFever, bone pain, malaise (or fever without focus).
SignsBony tenderness, warm, red, swollen.
Investigations blds iWCC, iESR, iCRP, blood cultures; ImagingX- ray (in-
sensitive since there are rarely changes in the rst 0d), USS (may show
periosteal lifting), MRI (gold standard);
Bone biopsyWhere indicated.
Culture Try to obtain a sample for microbiology prior to starting anti-
biotics (by swabs, USS- guided aspiration, or bone biopsy in theatre).
Treatment High- dose antibiotics (discuss with microbiology) for at least
6wk; often requires central access; surgical drainage of abscess if present.
ComplicationsSeptic arthritis, fracture, amputation, seeding to othersites.
Dry gangrene
$ Ischaemic muscle necrosis without infection.
SignsWell- dened, painless, shrivelled brown/ blackarea.
TreatmentDebridement or amputation may help prevent infection; alter-
natively conservative management awaiting autoamputation.
ComplicationsWet gangrene (an emergency:Ep. 469).
3Acute limb ischaemia
$ This is an emergency; ischaemia is irreversible after6h.
2
Worrying signs The 6 Ps: Pain, pallor, pulselessness, paraesthesia, par-
alysis, perishingly cold.
CausesEmboli, thrombosis, dissecting aneurysm, trauma.
Risk factorsArterial graft, peripheral vascular disease, previous thrombo-
emboli, AF, prosthetic heart valves, recent MI, dehydration, malignancy.
Symptoms Unilateral painful, tingling, weak limb, worse on raisinglimb.
Signs Absent pulses, slow cap rell (compare with opposite limb), cold
and pale (can be red if limb below heart), reduced power and sensation.
InvestigationsA hand- held Doppler probe will show a reduced or absent
pulse; angiography may demonstrate an obstruction.
TreatmentThis needs urgent surgery— call vascular surgery who will con-
sider embolectomy, intra- arterial thrombolysis, bypass, or amputation.
Analgesia (eg morphine); IV access with IV uids if dehydrated; may require heparinization (E pp. 428–30) pre- or post- op.
ComplicationsAmputation, gangrene, iK
+
, renal failure, sepsis.
3Gas (wet) gangrene
$ This is an emergency; Clostridium infection causing necrosis and sepsis.
Symptoms Unwell with painful extremities orwound.
Signs Pyrexia, systemic shock, tender brown/ black area with blistering
and oedema, muscle necrosis, crepitus (from gas in tissue).
Risk factorsIschaemia, DM, malignancy, surgery/ trauma.
Investigations blds FBC, U+E, LFT, CRP, CK, blood cultures, clotting;
ABGAcidosis; Gram stainOf pus or necrotic tissue; X- ray May show gas
(dark patches in soft tissues).
Treatment Call a senior surgeon who will consider urgent debridement.
Give 5L/ min O
cussion with microbiology (eg benzylpenicillin 2.4g/ 4h IV, clindamycin
, uids and broad- spectrum antibiotics upon urgent dis-
2
600mg/ 6h IV and metronidazole 500mg/ 8hIV).
ComplicationsAmputation, sepsis,death.
3Compartment syndrome
$ This is an emergency; call a senior surgeon if suspected.
Symptoms Excessive pain following an injury or fracture, distal tingling,
numbness or weakness, cool peripheries.
SignsPain at rest, worse on passive stretching of a muscle, reduced sen-
sation (loss of two- point discrimination), redness, swelling, slow cap rell; absent pulse and pallor are latesigns.
Risk factorsLong bone fractures and plaster casts, signicant injury, crush
injury, vascular injury, anticoagulants,burns.
Investigations Clinical diagnosis; blds FBC, U+E, CK, clotting; Compartment
Is measured by inserting a manometer through the skin (eg Wick
pressure
catheter), pressures >30mmHg indicate need for urgent fasciotomy, although some surgeons advocate avoiding intervention if pressure is
±20mmHg of diastolic pressure.
Treatment 5L/ min O
IV uids if dehydrated (monitor urine output); remove plaster cast if
present; consider urgent fasciotomy.
Complications Rhabdomyolysis, iK
; elevate limb (lie the patient at); analgesia;
2
+
, neurological damage, amputation.
469ACUTE LIMB PAIN
470 CHAPTER7 Emergency department
2Burns emergency
2 Airway
2 Breathing
2 Circulation
If airway involved— CALL ANAESTHETIST
If no respiratory eort— CALL ARREST TEAM
If no palpable pulse— CALL ARREST TEAM
3Call for senior help early if >0% burns or patient deteriorating. Burns pa-
tients require specialist help for every step of their management (Box 7.0).
Airway/ C- spine
• Immobilize the C- spine if C- spine injury suspected (Ep. 462)
•
Look for burns to the face and neck, singed eyebrows, facial hair, or
nasal hairs, soot around the nostrils or in the sputum, facial swelling
•
Listen for snoring noises, stridor, hoarsevoice.
3
If these above- listed features of an inhalational injury are present,
EARLY intubation is essential to prevent airway obstruction as the airway
starts to swell and obstruct; alert the anaesthetistearly.
Breathing
• 5L/ min O2 until carboxyhaemoglobin levels areknown
•
Count RR; rapid breathing suggests inhalationinjury
•
Monitor O
•
Escharotomy if circumferential chest burns restrict breathing.
satsandRR
2
Circulation
• Venous access, send bloodsfor:
•
FBC, U+E, glucose, clotting, G+S, and ABG for
carboxyhaemoglobin (CoHb)
•
Give 0.9% saline LSTAT
•
Give morphine IV (eg 0mg titrated to pain) and cyclizine 50mgIV
•
Monitor HR with debrillator ECG leads and BP for signs ofshock.
Disability
• Assess GCS and check glucose
•
Look/ feel for pupil reexes, limb tone, and plantar reexes.
Exposure
• Measure the extent of 2nd- / 3rd- degree burn, see Fig.7.3
•
Cover the burn with cling lm as analgesia, avoidcreams
• Check
temperature— keep the patientwarm!
Further resuscitation
• Calculate uid requirements and adjust rate accordingly (see ‘Burns
uid resuscitation’)
•
Catheterize to monitor urineoutput
•
CXR (for trauma and baseline as signs of inhalation injury after24h)
•
Monitor circulation of all limbs withburns
•
Reassess, starting with A, B, C...
2Box 7.0 Serious complications
HypovolaemiaEpp. 478–9
Carbon monoxide poisoningEp. 473
Inhalation injury E p. 473
Coexisting traumaEpp. 456–59
Limb ischaemiaEp. 469
Restriction of breathing E p. 284
BURNS EMERGENCY
Measuring theburn
Burn sizes are expressed as a percentage of the skin surface covered by 2nd-
or 3rd- degree burns. st- degree burns (erythema only) are not counted.
The Lund and Browder chart in Fig.7.3 works for children and adults.
The palm (not including ngers) of a patient ’s hand is about 0.75– %
of their body surface area and this can be used for smaller burns.
Alternatively, the ‘rule of nines’ can be used for adults (Table7.4).
Fig.7.3 Lund and Browderchart.
From Lund C.C., etal. The estimation of areas of burns. Surg Gynecol Obstet
944;79:352– 8. Reprinted with permission from the Journal of the American College of
Surgeons, formerly Surgery Gynecology & Obstetrics.
Table7.4 The ‘rule ofnines’
Head Each arm Each leg Trunk front Trunk back Perineum
9% 9% 8% 8% 8% %
471
Burns uid resuscitation
Calculate uid requirement for resuscitation as:
• (4 × weight (kg)) × percentage of burn=volume over 24h(mL).
Give half over the rst 8h after injury (ie over 6h if presented at2h):
• (Volume over 24h (mL) ÷ 2)÷ 8=rate per hour(mL).
The other half is given over6h:
• (Volume over 24h (mL) ÷ 2)÷ 6=rate per hour(mL).
So for a 70kg man with 30% burns the rate is 525mL/ h for the rst 8h then
263mL/ h for the next 6h. This is only a guide; monitor the volume status
and urine output to maintain volume (E p. 402). There is a signicant risk
of uid overload in these patients so monitor carefully.
472 CHAPTER7 Emergency department
Burns
2Worrying features HR >00, systolic BP <00mmHg, RR >30,
O
sats <92%, signs of inhalation injury, full thickness or circumferential
2
burn, res indoors, explosions, >0% skin involvement.
Think about Life/limb threatening E pp. 470–; Most likely Cutaneous
burns, chemical/ electrical burn, CO poisoning, non- accidental injury, associated injuries (fractures, wounds, eye/ ear trauma).
Ask about Mechanism of burn, time of burn, explosions, smoke, cause of
re, place where re occurred, duration of exposure, immediate treat ment,
falls/ jumping out of windows, trauma, breathing diculty,pain;
or respiratory problems, previous burns/ trauma;
SHSmoking (COHb result), housing (do they have somewhere togo?).
Look for 3Signs of inhalational injury (E p. 473)— get an immediate
anaesthetic assessment if those features are present, degree of burn
(Table7.5), colour, sensation, blistering, extent of burn, location of burn,
circumferential burns, other trauma.
Depth ofburn Assessed by the appearance, blanching, sensation, and
bleeding; it can be dicult to assess especially as dierent depths may be
close together so that a patient may report pain in an area of full thickness
burn. Burns will continue to evolve over48h.
Investigations bldsCOHb if re occurred inside; ConsiderABG,CXR.
Table7.5 Classifying burn severity
Depth Supercial Partial dermal Deep dermal Full thickness
Degree st 2nd 3rd
Colour Red Pink, blisters Bright red,
Blanching Yes Yes No No
Sensation Ye s Ye s Yes No
Bleeding Ye s Yes Slow No
DHAllergies, tetanus status;
mottled
White, brown,
black, leathery
PMHCardiac
Treatment
Major burns(>0% skin surface.) Resuscitate as per protocol (Ep. 47).
Minor burnsCool with running cold water for 0– 20min as soon as pos-
sible. Oer analgesia (E pp. 92–4) and cover burn with cling lm until
management has been determined. Refer to plastics for assessment if:
• Burns to the face, hand, or genitalia unless small and supercial
• Deep dermal/ full thickness burns larger than a postagestamp.
Ask for their advice on dressings (often minimal as some dressings alter
the appearance of the burn). See also Box7..
T Box 7. Tetanus
Burns can cause inoculation with tetanus; manage in the same way as
wounds (Ep. 459).