Acute Evaluation and Management in the Emergency Department

As with any trauma patient, a comprehensive and systematic approach, with the primary goals of resuscitation, should be undertaken. In the USA, specialized trauma centers institute the ABCDEs (airway, breathing, circulation, disability, exposure) of the Advanced Trauma Life Support, as dictated by the American College of Surgeon's Committee on Trauma. An emergency airway can be obtained by either oral or nasotracheal intubation. This is performed with the head and neck in a neutral position, with the help of an assistant. This technique of manual in-line traction helps avoid hyperextension of the neck, which, in the case of a cervical spine injury, will prevent worsening of canal stenosis as well as exacerbating motion of fractured segments or dislocations. Trauma to the head, chest, abdomen and musculoskeletal system occurs frequently in patients with spinal injuries. Because of this, some of these patients may present with signs and symptoms of shock. An assessment of pulse rate, skin, mental status and urine output helps to differentiate hemorrhagic from neurogenic shock, both of which present commonly with hypotension. Placement of an arterial line and a Swan Ganz catheter for proper hemodynamic assessment and subsequent management cannot be overemphasized. This helps to guide judicious use of intravenous fluids, which, if excessively administered, can lead to pulmonary edema and acute heart failure, especially in patients with pre-existing heart disease. The use of intravenous vasopressors, such as dopamine and neosynephrine, whether in a bolus or continuous infusion, is useful in reversing the effects of neurogenic shock. This type of shock is usually the result of loss of sympathetic tone in patients presenting with bradycardia and hypotension.

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