"Prehospital Management of Facial Trauma" was presented by Dr. Eric Lomax, a plastic surgeon practicing in Branson. Dr. Lomax emphasized the need for early airway control and neuro logic assessment of the head injured trauma patient, because the rapid development of facial edema obscures the pupils and obstructs the upper airway. Dr. Lomax noted that the eyes and lips are the "shock organs" of the face and develop edema rapidly after blunt facial trauma. The first responder must evaluate the pupils, look for lateralizing neurologic abnormalities and assess the level of con sciousness of the patient while securing the airway of the trauma patient with facial injuries. Changes in the level of consciousness, pupil size, and development of clinical signs of intracranial hypertension, i.e., hypertension, bradycardia, and irregular breathing patterns, must be documented. Dr. Lomax believes that in head and neck injuries "assume the worst until proven otherwise."
"Resuscitation ParadigmsThe Ultimate Moving Target" was presented by Dr. Matthew Wall, Medical Director of Trauma Services at Ben Taub Hospital, Houston. Dr. Wall encouraged constant reevaluation of our trauma resuscitation "sacred cows." This herd includes: the value of mast trousers, high volume fluid resuscitation in penetrating injuries of the torso, and the value of CPR in the moribund trauma patient.
Dr. Wall presented data from a study at Ben Taub that demonstrated the limitations of MAST Trousers and massive fluid resuscitation in certain groups of trauma patients. "Intravenous fluid infusions, although theoretically of value in a hypovolemic patient, may actually be deleterious in those with uncontrolled hemorrhage. Recent studies have begun to suggest a harmful effect of rapid intravenous fluid infusions before surgical control of a major vascular injury. Similarly, pneumatic antishock garments should be of little value, since they primarily elevate cardiac afterload and their application usually delays evacuation. In several studies of patients with penetrating thoracic inju ries, pneumatic antishock garment use has been shown to increase mortality." (J. Trauma 36: 132, Jan. 1994) Dr. Wall believes MAST Trousers may be of benefit in lower extremity fractures and pelvic fractures.
He emphasized that the one supportive intervention that does appear to be of value in the moribund trauma victim is prehospital endotracheal intubation. Endotracheal intubation extends the tolerance of circulatory arrest by more than five minutes. (J. Trauma 32: 775, 1992) Dr. Wall noted there are "anomalies of resuscitation techniques" that use deliberate hypotensive therapies in certain situations, e.g., dissection of the thoracic aorta, expanding abdominal aortic aneurysm, and gas trointestinal hemorrhage. "Over resuscitation" with crystalloid solutions has resulted in the appear ance of the "Da Nang Lung," i.e., diffuse pulmonary edema and the need for ventilator support.
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