PRIORITIES IN THE MANAGEMENT OF MULTIPLE TRAUMA - INTRACRANIAL VERSUSINTRAABDOMINAL INJURY

Setting priorities in the management of patients with suspected injuri es to both the head and the abdomen is difficult and depends on the li kelihood of different injuries. Eight hundred trauma patients were ret rospectively reviewed to determine the likelihood of a surgically corr ectable cerebral injury. All 800 patients, at the time of initial eval uation, were thought to have potentially correctable injuries to both the head and the abdomen. Of these, 52 had a head injury requiring cra niotomy; 40 required a therapeutic celiotomy. Only three patients requ ired both craniotomy and therapeutic celiotomy. There were more cases of delay in therapeutic celiotomy because of negative results of compu ted tomographic (CT) scanning of the head (13 cases) than there were d elays in craniotomy because of nontherapeutic celiotomy (four cases). Need for craniotomy, based on emergency department evaluation, was ind icated by the presence of lateralizing neurologic signs. Low Glasgow C oma Scale score, anisocoria, fixed/dilated pupils, loss of consciousne ss, facial or scalp injuries, and age were of no independent value in predicting the need for craniotomy. Conclusions: Patients with surgica lly correctable injuries of both the head and the abdomen are rare. In stable patients with altered mental status and potential injuries to both the head and the abdomen, the abdomen is best evaluated first by diagnostic paracentesis. If paracentesis does not return gross blood, CT scanning of the head should be done. If gross blood is obtained and there are no lateralizing signs, it is best to proceed directly to ce liotomy without first obtaining a CT scan of the head. If gross blood is obtained on initial paracentesis and there are lateralizing signs, CT scan of the head should be obtained before celiotomy. The likelihoo d of a treatable brain injury in patients with lateralizing signs is h igh enough that the head should take precedence over the abdomen.