51.3 Some particularly difficult combined injuries

Although a patient can have almost any combination of injuries, there are some pairs of injuries in which one of the pair is often missed. If you find the more obvious injury of the pair, look for the other one.

A head injury and an injury of the patient’s cervical spine. The same force can easily produce both these injuries. The patient may be unconscious from his head injury and so unable to complain of pain in his neck. Later, he may recover from his head injury only to find himself quadriplegic, or with a severe injury to his brachial plexus. So, if a patient has a head injury, suspect that he may have a neck injury also.

A neck injury and obstruction to a patient’s upper respiratory tract. This can be the result of a severe injury to his lower jaw. Support his head and neck continuously in a neutral position, until you have seen AP (anteroposterior) and lateral X-rays of his cervical spine. Hyperextending his neck to look at his larynx, or to intubate him, may damage his cervical spine seriously. Careful nasotracheal intubation or a temporary laryngotomy is safer.

An abdominal injury combined with any other severe injury, particularly a head injury. A severe injury elsewhere may distract your attention from a patient’s abdomen. If he is unconscious he may be unable to complain of abdominal pain. Examine him carefully, review him frequently, and, if necessary, use the special methods in Section 66.1.

A chest injury and an abdominal injury. This is a common and difficult combination. Both the surgery and the anaesthesia for a thoracotomy are too difficult to be described here. If you cannot do one, at least be sure to: (1) insert a chest drain with an underwater seal before you operate, and (2) intubate the patient.

Multiple injuries and a haemothorax. A haemothorax would not be so deadly if it were not so easily missed. It may not be noticeable on the initial X–ray, especially in an AP film, but blood may accumulate slowly and silently over several days after the initial X–ray. So if a patient has multiple injuries, watch for a haemothorax over a week or more.

Other common combinations. (1) A chest injury and an injury to a patient’s thoracic spine. (2) A fracture of his femur and a dislocation of his hip on the same side (77.4). (3) A fracture of his pelvis with a rupture of his urethra, and less often his diaphragm. (4) A pelvic fracture, a lumbar fracture, and paraplegia.

RAM (28) was one of several casualties brought in about 10 p.m. after a road accident. It had been a difficult night, and there had already been an emergency Caesarean section that evening. He did not look particularly ill and his blood pressure was normal, but surgical emphysema was observed over his left chest. Another patient had a severe malleolar fracture so RAM was second on the list. By 2 a.m. he was severely shocked, and was thought to have an abdominal injury. The anaesthetic assistant gave him ketamine and intermittent suxamethonium, but was unable to intubate him. His ruptured spleen was successfully removed, and a rupture in his diaphragm repaired, but he died just before the equipment for a chest drain could be assembled. LESSONS (1) If a patient has a chest injury, it usually takes precedence over that to his abdomen. (2) If you cannot do a thoracotomy at least drain his chest using an underwater seal. (3) A sterile chest drain set must always be instantly available (65.2).

Figure 51.7: ONE CAUSE OF MASS CASUALTIES. Fourteen people died in this crash on the Kaduna-Zaria road. Several others were seriously injured. Better driving instruction and stricter driving examinations might have prevented it.