CHAPTER 4 Shock and trauma
Shock
Hypovolaemic shock
Symptoms and signs
Treatment
Shock is a surgical emergency and needs rapid treatment.
Septic shock
Treatment
Cardiogenic shock
Causes
Investigations
Urgent investigations include portable CXR, FBC, U&E, cardiac enzymes, D-dimers, ABGs, ECG, CXR.
Neurogenic shock
Trauma
Initial assessment of the trauma patient
Primary survey
ABCDE of emergency management:
Secondary survey
The secondary survey is a head-to-toe evaluation of the trauma patient, i.e. a complete history and physical examination, including a reassessment of all vital signs. Each area of the body should be completely examined. A full neurological examination is carried out including a GCS (Glasgow Coma Score) determination (Table 4.1).
Responses | Score |
---|---|
Eye-opening response | |
Spontaneous | 4 |
To voice | 3 |
To pain | 2 |
None | 1 |
Best verbal response | |
Orientated | 5 |
Confused | 4 |
Inappropriate speech | 3 |
Incomprehensible speech | 2 |
None | 1 |
Best motor response | |
Obeys commands | 6 |
Localizes pain | 5 |
Withdraws to pain | 4 |
Flexion to pain | 3 |
Extension to pain | 2 |
None | 1 |
Total | 3–15 |
A score of 3 indicates a severe injury with a poor prognosis. A score of 13–15 indicates minor injury with a good prognosis.
Examination
Head injury (→ Ch. 18)
Management
The management of specific head injury is dealt with in the section on Neurosurgery (→ Ch. 18) but the basic principles are outlined here as far as trauma management is concerned.
Hypotension in adults is not due to intracranial blood loss. However, in children, significant blood loss can occur in head injuries and can be responsible for hypotension. The scalp should be examined for lacerations and boggy wounds. Observation should be made for bleeding and CSF leakage from the ear and nose. The cranial nerves should be checked and the limbs examined. Assessment of head injured patients include skull X-rays and CT scan; indications for these are detailed in Chapter 18.