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Fractures of the humerus

Essentials 1 Fractures of the proximal humerus occur primarily in the elderly, whereas distal humeral fractures occur more often in children. 2 Falls producing fractures in elderly patients are often precipitated by an underlying medical problem that should be sought for and managed. 3 Most proximal humeral fractures do not require surgical intervention. 4 The aim of treatment is to minimize pain, maximize the return of…

Dislocations of the elbow

Essentials 1 Elbow dislocations are the third most common large joint dislocations. 2 Surgical intervention is rarely required for simple elbow dislocations. 3 Surgical intervention may be required when fractures of the radius, ulna and humerus are associated with elbow dislocation or when neurovascular injury occurs. 4 The commonest neurovascular complication involves the ulnar nerve. 5 After reducing elbow dislocations, it is important to reassess joint…

Injuries of the shoulder

Essentials 1 Most clavicular fractures heal despite displacement; therefore reduction is not necessary. 2 Injuries to the shoulder region may also involve injury to local neurovascular structures. 3 Acromioclavicular joint injuries and fractures of the scapula are usually treated conservatively. 4 Posterior sternoclavicular dislocations require reduction. 5 In dislocation of the shoulder, careful examination of the axillary (circumflex) nerve, brachial plexus and axillary artery is mandatory…

Massive transfusion

Essentials 1 Early prediction of massive transfusion and activation of massive transfusion guidelines can ease some of challenges of resuscitation. 2 Systems should be instituted for effective prenotification of patients at risk of massive transfusion and a team-based approach to resuscitation planned, with the emergency physician as the team leader. 3 Laboratory tests may require a considerable amount of time to provide results and are not…

Burns

Essentials 1 Effective triage and advances in the treatment of severely burned patients, including judicious fluid resuscitation, control of sepsis, early excision and use of skin substitutes, have made previously lethal burns survivable. 2 Signs of impending or developed laryngeal oedema should prompt early intubation. 3 Burn resuscitation formulae should be considered as a guide only. 4 Meta-analysis of previous studies suggests that resuscitation with colloid…

Wound care and repair

Essentials 1 Good cosmesis can be achieved in the emergency department with conservative treatment, thorough debridement and accurate apposition of everted skin edges. 2 Choose a suture that is monofilament, causes little tissue reactivity and retains tensile strength until the strength of the healing wound is equal to that of the suture. 3 Dirty, contaminated, open wounds should generally be cleansed, debrided and closed within 6…

Trauma in pregnancy

Essentials 1 Trauma in pregnancy is the most common cause of non-obstetric maternal death, with most deaths due to head injury and haemorrhagic shock. 2 Fetal death occurs more often than maternal death and is dependent on the severity of the maternal injuries. Placental abruption and direct fetal trauma cause most fetal deaths. 3 Common causes of trauma are motor vehicle collisions, falls and assaults. 4…

Radiology in major trauma

Essentials 1 The initial trauma series x-rays should include a chest x-ray (CXR) and pelvic x-ray (PXR). Computed tomography (CT) of the cervical spine is essential to rule out a major fracture 2 CT of the brain will rule out most types of intracranial haemorrhage but not diffuse axonal injury (DAI), which is best diagnosed by magnetic resonance imaging (MRI). 3 CT of the cervical spine…

Limb trauma

Essentials 1 Optimal trauma resuscitation and fracture management will reduce limb and life-threatening complications. 2 Skin under pressure over a fracture is an orthopaedic emergency. 3 Fracture management consists of reduction, immobilization and rehabilitation. 4 Specific limb trauma assessment is part of the secondary survey. 5 Early renal replacement therapy is potentially life saving in crush syndromes. Introduction Injuries to the limbs account for most of…

Chest trauma

Essentials 1 Initial management priorities are oxygenation, ventilatory support if required, pleural and pericardial decompression when indicated, circulatory support, adequate analgesia and early imaging to identify evolving and potentially life-threatening injuries. 2 Less than 10% of blunt chest trauma patients require thoracic surgery. 3 Supine chest radiographs do not reliably exclude haemothorax, pneumothorax, aortic transection, diaphragmatic disruption, cardiac tamponade or rib, sternal, thoracic spine and scapula…

Abdominal trauma

Essentials 1 One in 10 deaths from trauma is due to abdominal injuries. 2 Abdominal injuries may be occult—overshadowed by more apparent external and orthopaedic injuries—and may be missed initially. 3 Detection of intra-abdominal injuries requires a high index of suspicion to avoid preventable morbidity and mortality. 4 Computed tomography scanning provides organ-specific diagnosis but requires sufficient stability for transfer from the resuscitation area. 5 Bedside…

Facial trauma

Essentials 1 Facial trauma occurs as isolated injury with assault, sporting mishaps, falls and as part of complex multisystem injury. 2 Immediate threat to life may relate to airway obstruction or local haemorrhage; however, threat to life is mostly due to associated injuries. Therefore assessment of facial trauma usually takes place in the secondary survey. 3 It is vitally important to understand the relationship between structure…

Spinal trauma

Essentials 1 Clinically significant cervical spine injury can be confidently eliminated in conscious, clear-headed patients below 65 years of age using clinical examination criteria (as described in National Emergency X-Radiography Utilization Study (NEXUS) and Canadian C-spine rules) alone. 2 Physical examination alone does not assist in the diagnosis of unstable vertebral injury unless the deformity is gross. 3 A lack of neurological symptoms and signs does…

Neurotrauma

Essentials 1 Neurotrauma is the most common cause of death in trauma. 2 A detailed history of the mechanics of the trauma experienced is invaluable. 3 Secondary brain injury is a major and potentially preventable cause of mortality and long-term morbidity. 4 Cerebral cellular dysfunction secondary to trauma is a result of both primary and secondary mechanisms and involves sodium, calcium and potassium shifts across the…

Trauma overview

Essentials 1 Injuries cause 9% of all deaths. 2 Trauma remains the leading cause of death in those aged from 1 to 44 years in the most highly developed countries. The burden of injury is especially high in developing countries. 3 Improvements in trauma care systems have resulted in fewer patients dying from avoidable factors and less disability. 4 The key objective of a mature trauma…

Anaphylaxis

Essentials 1 The term anaphylaxis describes both immunoglobulin E (IgE) immune–mediated reactions and non-allergic, non-immunologically triggered events. Co-morbidities—such as asthma, infection, exercise, alcohol and stress or concurrent medications such as β-blockers, angiotensin converting enzyme inhibitors and aspirin—increase the risk (‘summation anaphylaxis’). 2 Deaths occur by hypoxia from upper airway asphyxia or severe bronchospasm or by profound shock from vasodilatation and extravascular fluid shift. 3 Parenteral penicillin,…

Cerebral resuscitation after cardiac arrest

Essentials 1 Neurological injury is common following out-of-hospital cardiac arrest and carries a high rate of morbidity and mortality. 2 Successful resuscitation leads to reperfusion of an ischaemic brain, and this may result in biochemical cascades, largely mediated by calcium influx into cells, promoting cell death. 3 In the early post-arrest period, the appropriate targets for oxygen, carbon dioxide, blood pressure and temperature are all uncertain,…

Arterial blood gases

Essentials 1 The value of arterial blood gas analysis is dependent on understanding and correctly interpreting the results in the clinical context. 2 When abnormalities are detected with arterial blood gas analysis, make sure that the sample was obtained, transported and analysed appropriately. 3 An arterial blood gas result assists in the assessment of a patient’s gas exchange, ventilatory control and acid–base balance. 4 Common sampling…

Sepsis and septic shock

Essentials 1 Early recognition and intervention in the emergency department reduces mortality in patients with sepsis and septic shock. 2 Appropriate broad-spectrum antibiotics should be administered within 1 hour of the recognition of sepsis. 3 Systemic blood pressure, serum lactate levels, and urine output should be monitored closely to determine the effectiveness of treatment. Introduction Sepsis is a leading cause of preventable death worldwide. Current estimates…

Shock overview

Essentials 1 Broad categories of shock include disorders of intravascular volume, vascular resistance, cardiac filling and the myocardial pump. Overlapping aetiologies are commonly encountered. 2 Hypotension is only one characteristic of shock, which should be considered a late and concerning finding. 3 Hypovolaemia and hence the need for volume resuscitation is a concern in every patient with shock. 4 Interventions in any form of shock are…