Sun28November0628PM 36

You are asked to review a 24-year-old driver who has been admitted to the Emergency Department after a high-speed accident. He has a GCS of 15 and has been talking. He is now dyspnoeic despite 40% oxygen. His pulse rate is 160 beats per minute and blood pressure 70/40mmHg. A chest drain has been inserted that drained 2400mL of blood initially and a further 400mL in the next 30 minutes. No other injuries are apparent.

Which is the single most important next step in his management?

(Please select 1 option)

Request a repeat full blood count to establish how much blood will be needed

Arrange an urgent CT scan without further investigations

Arrange urgent x rays of his chest, pelvis and cervical spine

Perform a head to toe examination to exclude other injuries

Arrange theatre for an urgent exploratory thoracotomy Correct

Explanation

Following thoracic trauma a thoracotomy will be required in about 10% of patients. A haemothorax will usually result from injury either to the lung itself or venous injury and will usually stop bleeding without active intervention. However arterial haemorrhage resulting from penetrating trauma is more likely to require emergency surgery.

The indications for thoracotomy are usually quoted as the immediate drainage of 1000-1500mls of blood from a chest drain followed by ongoing loss. The threshold for this is usually at 200-250mL per hour or more and should be expedited if there is haemodynamic compromise. The most important step in this patient's management is an arterial clamp and/or the suture of bleeding vessels.

Sending a haemodynamically compromised patient to the x ray department will merely delay inevitable surgery.

A head to toe examination has already been carried out, as "No other injuries" are apparent including a C-spine clearance. Even if the C-spine injury cannot be 100% excluded, the patient should be anaesthetised with this borne in mind.

Requesting a repeat full blood count will not necessarily be a guide to blood loss as the patient may or may not be haemodiluted depending on the degree of fluid resuscitation.

Answer Statistics

1

3%

2

7%

3

1%

4

9%

5

82%

Times answered: 272