Trauma assessment

On Friday prof and I spent a tricky half hour debating whether to take a patient to theatre for a craniotomy. He had been stood on a two metre platform at work, adding caustic soda to a vat of boiling water. Unfortunately, but not unexpectedly, the resultant mix had erupted into his face, giving him 20% chemical burns, a horrific chemical burn to both eyes and causing him to fall on his head.

When he arrived with us three hours later he was comatose. He had been walking around and talking for an hour post injury, but then started fitting on his arrival at a rural clinic one hour later. He had been sedated then transferred here.

The eye injuries and burns, while tragic, were not immediately life-threatening. His story was however suggestive of an extra-dural haemoatoma, which would need immediate decompression. In the UK, in this situation, a CT scan gives a rapid and conclusive answer. Here, we do a clinical assessment and make a decision as best possible with what is available. We have not done a single craniotomy since I arrived, although we came close when we had a comatose 6 year old with a depressed skull fracture. He however woke up before I could get him to theatre - a near miss!

Unfortunately, one of the key parts of the clinical assessment of a head injur is the pupil reaction - something we did not have due to the ocular injury. We spent some time checking his reflexes and muscle tone, and response to painful stimuli. The initial conclusion was that he was hypertonic, but bilaterally so, and possibly still fitting. So, after a further dose of diazepam he was still unconscious but less stiff, and crucially the same on both sides. So no craniotomy indicated. We managed him lying on his side, hoped he did not have an unstable spinal injury and tried to stop him aspirating any vomit. He is now starting to wake up 24 hours later.

Being in the position, on an almost daily basis, of having to make critical decisions with minimal diagnostic support, has given me a new attitude and new set of skills in patient assessment. I am looking forward to having a CT scanner sat waiting to help me with the answer on my return, but I am also expecting to make much better use of my clinical skills before doing the scan!