The entire scalp and head are examined for lacerations, contusions, and evidence of fractures. Although edema around the eyes may later preclude an in-depth examination, the eyes should be evaluated for injury, visual acuity, and pupillary size. If there is any suspicion that the patient may have a significant intracranial lesion requiring surgery, a prompt head CT should be performed; however, in general a patient should not be sent for a CT scan while hemodynamically unstable.
Many facial fractures can be detected more readily by physical examination than by radiography. If the teeth do not fit together normally, a maxillary or mandibular fracture should be suspected and Panorex films should be taken. Radiographs or Ct scans of the face are not usually necessary in the emergency department if the patient is going to be admitted.
Patients with head, facial, or neck trauma should be assumed to have an unstable cervical spine injury, and the neck should be immobilized until all aspects of the cervical spine have been adequately studied and an injury excluded. However, the absence of neck pain, neck tenderness, and distracting injuries in an awake and alert adult who has not taken mind-altering drugs is usually sufficient to exclude a cervical spine injury.
If a cervical collar is in place, it can be removed to examine the neck while another person stabilizes the head. Cervical spine tenderness, subcutaneous emphysema, tracheal deviation, and laryngeal fracture may be noted on palpation if the patient is not intubated. Any change in voice should raise suspicion of a laryngeal injury. The carotid arteries should be auscultated for bruits.
Patients with a high spinal cord injury are vasodilated and tend to have a systolic blood pressure of only 80 to 90 mmHg. In addition, the pulse rate tends to be normal and the skin is relatively warm and dry. If a patient with a high spinal cord injury has tachycardia or a systolic blood pressure less than 80 mmHg, he or she is probably hypovolemic but may also have cardiac injury.
With penetrating neck trauma, wounds that extend through the platysma should not be explored manually in the emergency department. This type of injury requires evaluation in the operating room or with angiography, endoscopy, and/or contrast studies to rule out vascular and aerodigestive tract injuries.
Inspection of the chest, both anterior and posterior, may identify conditions such as sucking chest wounds and flail segments. When the back is to be examined, the patient must be logrolled to avoid aggravating any spinal injury that may be present. The entire chest cage must be carefully palpated. Contusions and hematomas of the chest wall should alert the physician to the possibility of internal injury. However, up to 30 to 40 per cent of patients with severe intrathoracic injuries, particularly younger patients, have little or no external evidence of trauma.
Echocardiography is a non-invasive and relatively inexpensive means of evaluating patients with a possible myocardial contusion or tamponade. It can also detect acute valvular injury, pericardial effusions, or intracavitary clots.
Chest radiography can detect many pneumothoraces that are not apparent clinically; however, up to 1000 ml of hemothorax may not be apparent on a supine chest radiograph. A certain number of 'occult' pneumothoraces are seen on CT scans of the chest or abdomen but not on chest radiographs. An 'occult pneumothorax' can be observed if the patient is not on a positive pressure ventilation. Rib fractures may be present, but up to 50 per cent of these are not visualized on the initial radiographs, and radiographs with rib detail add nothing to management.
Although complete absence of a mediastinal hematoma on CT scan may be helpful for excluding traumatic rupture of the aorta, an aortogram should be performed in suspicious cases. Transesophageal echocardiography can be very useful for evaluating a possible traumatic rupture of the aorta, particularly in patients too unstable to go to the angiography suite, but it should not replace aortography ( Shapiro ela[ 1.991; Kearney ei al 199.3).
A normal initial examination of the abdomen does not exclude a significant intra-abdominal injury because some injuries may not cause pain or tenderness for up to 12 to 24 h. In addition, alcohol, illicit drug use, or a head or spinal cord injury may preclude a reliable examination. Close observation and frequent re-evaluation of the abdomen, preferably by the same observer, is important for detecting such injuries early. Fractures of the pelvis or the lower rib cage may also hinder adequate examination of the abdomen, because pain from these areas may be elicited when palpating the abdomen.
Patients with equivocal physical findings, unexplained hypotension, or an impaired sensorium secondary to trauma, alcohol, or other drugs should be considered as candidates for a peritoneal lavage. CT scans and ultrasound can also be used to evaluate the abdomen. The CT scan is particularly useful for evaluation of retroperitoneal structures, such as the kidneys and pancreas, but can easily miss bowel injuries.
Ultrasound is being used increasingly as a screening tool for hemoperitoneum in blunt trauma. In a collected series of 4000 trauma patients, ultrasound was used to detect hemoperitoneum and/or pericardial effusion in injured patients with a 93.4 per cent sensitivity and 98.4 per cent specificity ( Rozycki.and.Shackford 1996).
Perineum, rectum, and vagina
The perineum should be examined carefully for contusions, hematomas, lacerations, and urethral bleeding. On rectal examination the physician should assess for blood, a high-riding prostate, the presence of pelvic fractures, the integrity of the rectal wall, and the quality of the sphincter tone. In females, a vaginal examination is essential to assess for the presence of blood or injuries in the vaginal vault. A pregnancy test should be performed on all females of childbearing age.
The extremities should be carefully examined for tenderness, crepitation, or abnormal motion. The stability of any pelvic fractures should also be evaluated as a possible source of major occult blood loss. Impaired sensation and/or loss of voluntary muscle strength may be due to nerve or vessel injury or compartment syndrome.
Perfusion of injured extremities should be monitored closely. An arteriogram is the gold standard for evaluating arterial injuries, but Doppler ultrasound examination is a good screening modality. If compartment syndrome is suspected, compartment pressure can easily be determined at the bedside with a hand-held monitor or using an arterial line set-up. Normal compartment pressures range from zero to 8 mmHg, and decompression should be considered for pressures greater than 30 mmHg.
A comprehensive neurological examination includes not only motor and sensory evaluation of the extremities, but also continued re-evaluation of the patient's level of consciousness and pupillary size and response. The intracranial pressure should be monitored in any patient with suspected intracranial mass lesion. A decrease of 2 or more in the Glasgow Coma Scale should prompt urgent neurosurgical evaluation.
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