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By Drs. H.M. Husein

A 22-year-old man sustain a shotgun wound to the left
shoulder. His blood pressure is initially 80\40 mmHg.
After 2 liter of Ringer lactate solution his blood pressure
increases to 122/84 mmHg. His heart rate is now 100
beats per minute and his respiration rate is 28 beats per
minute. His breath sounds are decreased in the left
hemithorax, and a closed tube thorascostomy is
performed with the return of a small amount of blood and
no air leak. The most appropriate next step is to :
Reexamine the chess, Perform an aorthagram, Obtain a
CT scan of the chest, Perform transoesophageal
echocardiography.
A 36-year-old woman is beaten about the head and face, and is
brought to a local community hospital in full immobilization. His
blood pressure is 130/88mmHg, heart rate is 70 beats per minute,
and respiration rate is 18 breaths per minute. The pulse oximeter
indicated 96% hemoglobine saturation while she is being given
100% oxygen via a nonbreathing mask.Her airwav is clear. She has
marked swelling of her face and several superficial lacerations of her
scalp that are not actively bleeding.she does not respond to verbal
stimuli,but localizes to painful stimuli and opens her eyes.she moves
all exlremities equally.The remainder of her physical examination is
normal.There is no neurosurgeon at the local hospital.After ensuring
a patent airway,the most appropriate course of action is to : Admit
the patient to the hospital for observation, Obtain x-ray of her facial
bones prior to transfer, Obtain complete x-ray evaluation of the
cervical spine,Transfer the patient to a neurosurgeon without
performing a CT scan, Perform diagnostic peritoneal levage or
request abdominal ultrasonography.

A 25-yaer old man is brought to the hospital after geeing
involved in a motor vehicular crash when his car struck a
bridge abutment. He is intoxicated, has a GCS score of
13, and complains of abdominal pain. His blood pressure
was 80 mmHg systolic by palpation on admission to the
hospital, but it rapitly increased to 110/70 mmHg with the
administration of intravenous fluids. His heart rate is now
120 beats per minute. The chest x-ray shows loss of the
aortic knob,widening of the mediastenum, no rib
fractures, and no homopneumothorax. Contrast
angiography : Is not indicated, should be performed after
a CT scan of the cheat, is positive for aortic rupture in
80% of similar cases. Is not necessary if the CT scan of
the chest is normal. Should be performed after
diagnostic peritoneal lavage.

A 23-year old man sustains 4 stab wounds to the upper
right chest during an altercation and is brought by
ambulance to a community hospital that has has full
surgical capabilities .The wounds are all above the
nipple.He is endotracheally intubated,closed tube
thoracostomy is performed,and 2 liters of Ringer lactate
solution are infused through 2-large caliber IVs. His
blood pressure now 60/0 mmHg. Heart rate is 160beats
per minute, and respiratory rate is 14 breaths per minute
( ventilated with 100 % O2 ) Themost appropriate next
step in managing this patient is :
angiography,thoracotomy,CT scan of the
chest,application of PASG, immediate transfer to a
trauma certer.