Amarissa Alya Tsabita

18/425487/KU/20536
Group 3 - PD IUP 2018

TIMBUL Block D.1 Scenario 3

• What is the laboratory and X-ray examinations for emergencies patients in circulation
disorders including trauma maxillofacial, cervical, inhalation trauma, choking, near
drowning, aspiration?
A. Trauma Maxillofacial
Laboratory testing on trauma patients generally includes evaluation of hematological
profiles and blood chemistries including sodium, potassium, chloride, blood urea nitrogen,
creatinine, glucose, and amylase levels. In addition, clotting profiles are usually obtained
for these patients.

The patients had a complete blood count, blood coagulation testing, a blood chemistry
analysis, and a urinalysis. The complete blood count comprised the number of erythrocytes,
platelets, leukocytes, neutrophils, including bands and segmented neutrophils, eosinophils,
lymphocytes and monocytes (cells/μL), hemoglobin (g/ dL), and hematocrit (%). The
coagulation tests comprised prothrombin time (PT) (%) and activated partial
thromboplastin time (aPTT) (international normalized ratio = INR). The blood chemistry
tests comprised glucose, urea and creatinine (mg/dL), sodium (Na), and potassium (K)
(mmol/L). For the urinalysis, the values of density, pH, and leukocyte and erythrocyte
counts (cell/mL) were obtained.

Until a few years ago, clinical evaluation assisted by conventional X rays were the imaging
standard for cranio cerebral and facial trauma. Today, however, computed tomography
(CT) has become the primary imaging method, along with significant technical
improvement, especially with the development of multislice CT. CT enables a precise
diagnosis of all kind of fractures of the facial skeleton and skull base, and additionally
delivers information about intra cranial bleeding and injuries to cerebrum. In the panfacial
trauma patients, CT can be extended to the cervical spine as well as trunk if necessary.

B. Cervical Trauma
For any patient thought to have a neck injury, obtain the standard trauma blood studies
(CBC count, electrolytes, other warranted blood chemistry levels, blood type and
crossmatching).

Generally, a CBC count and blood typing suffice in a previously healthy individual, but
patients with comorbid disease or those in shock may require additional studies, including
a determination of coagulation profiles. Obtain alcohol and toxicology screens, when
indicated.
Unless indicated otherwise, most patients sustaining significant injury to the neck require
plain-film radiography. Although not helpful in most cases of vascular or related soft tissue
injury to the neck, anteroposterior (AP) and lateral films may help in localizing a foreign
body. However, in many trauma centers, helical CT scans are supplanting plain cervical
films for all patients with significant neck injuries. Review the cervical radiographs for
emphysema, fractures, displacement of the trachea, and presence of a foreign body (eg,
missile fragments).

Any finding suggestive of a zone I wound or damage to the thoracic cavity mandates
obtaining a chest radiograph. Circumspectly review the film for hemothorax,
pneumothorax, widened mediastinum, mediastinal emphysema, apical pleural hematoma,
and foreign bodies.

Obtain supplementary tests in the stable patient if specific system injuries are suggested by
the history, physical, or prior ancillary studies. Additional imaging studies include the
following: CT, MRI, color flow Doppler studies, contrast studies of the esophagus,
interventional angiography, and endoscopic images.

C. Inhalation Trauma
There are several modalities for confirming inhalation injury to include fiberoptic
bronchoscopy (FOB), chest computed tomography (CT), carboxyhemoglobin
measurement, radionuclide imaging with 133Xenon, and pulmonary function testing.

Initial blood tests should include lactate and CO-oximetry in addition to electrolytes and
arterial blood gases.

D. Choking
Initial laboratory evaluations should be limited to specific studies based on the differential
diagnosis generated after the completion of a history and physical examination. A complete
blood count screens for infectious or inflammatory conditions. Thyroid function studies
may detect hypo- or hyperthyroid-associated causes of dysphagia which usually present
with complaint of choking (e.g., Grave's disease or thyroid carcinoma).

Other tests may include:

• X-ray with a contrast material (barium X-ray). You drink a barium solution that
coats your esophagus, allowing it to show up better on X-rays. Your doctor can then
see changes in the shape of your esophagus and can assess the muscular activity.

Your doctor may also have you swallow solid food or a pill coated with barium to watch
the muscles in your throat as you swallow or to look for blockages in your esophagus
that the liquid barium solution may not identify.
• Imaging scans. These may include a CT scan, which combines a series of X-ray views
and computer processing to create cross-sectional images of your body's bones and soft
 tissues, or an MRI scan, which uses a magnetic field and radio waves to create detailed
images of organs and tissues.

E. Near Drowning

Obtain arterial blood gas (ABG) levels in all patients with any history of submersion injury.
ABG analysis should include co-oximetry to detect methemoglobinemia and
carboxyhemoglobinemia.

Obtain blood for a rapid glucose determination, complete blood count (CBC), electrolyte
levels, lactate level, and coagulation profile, if indicated. Collect urine for urinalysis, if
indicated. Measure liver enzymes, especially aspartate aminotransferase and alanine
aminotransferase. Consider a blood alcohol level and urine toxicology screen for use of
drugs. Cardiac troponin I testing may be useful as a marker to predict children who have
an elevated risk of not surviving to hospital discharge.

If initial test results show elevated serum creatinine level, marked metabolic acidosis,
abnormal urinalysis, or significant lymphocytosis, serial estimations of serum creatinine
should be performed.

Chest radiography may detect evidence of aspiration, pulmonary edema, or segmental

atelectasis suggesting the presence of foreign bodies (eg, silt or sand aspiration). It may
also be used for evaluation of endotracheal (ET) tube placement. Extremity, abdominal, or
pelvic imaging may be used if clinically indicated.

A cervical spine radiograph or computed tomography (CT) scan is indicated in individuals

with a history of possible cervical trauma or with neck pain or if doubt exists about the
circumstances surrounding the submersion injury. Noncontrast head CT scanning is also
indicated in an individual with altered mental status and a suggestive or unclear history.

F. Aspiration
• Laboratory studies in a thorough evaluation should include the following:
1. CBC count with manual differential
2. ABG or pulse oximetry
3. Sweat chloride
4. Pulmonary function test
5. Serum immunoglobulin G (IgG), immunoglobulin M (IgM), immunoglobulin A
(IgA), and immunoglobulin E (IgE) levels (possibly)
• Skin prick testing, allergen-specific serum IgE, and/or food atopy patch testing to
common foods may be performed if eosinophilic esophagitis is considered in the
differential diagnosis.
Chest radiography may reveal hyperinflation; marked diffuse interstitial or perihilar
infiltrates, unilateral or bilateral; peribronchial thickening; pleural effusion; lobar or
segmental consolidation; bronchiectasis; or atelectasis.
 High-resolution chest CT scanning may reveal bronchial thickening, bronchiectasis,
ground-glass opacities, tree-in-bud centrilobular opacities, and air trapping.
Barium esophagram is used to evaluate for anatomic or physiologic abnormalities of
the upper GI tract, to quantify the degree of aspiration during swallowing, and to assess
texture-specific foods and swallowing. Anatomic abnormalities, including a hiatal
hernia, malrotation, pyloric stenosis, and antral or duodenal webs, may be diagnosed
and may predispose an individual to gastroesophageal reflux (GER).
Gastroesophageal scintigraphy, is a radionuclide study that provides a more functional
or physiologic assessment for GER and aspiration. Food of formula labeled with a
radionuclide is introduced and the patient is scanned for evidence of reflux and
aspiration for one hour.

References

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