Diagnosis and monitoring

Equipment and associated expertise for the diagnosis and monitoring of injured patients have been addressed in each of the preceding sections. Because of the overlapping requirements for many of these, all are repeated in this section, along with several that have not previously been discussed. The rationale for most of these items has been discussed above and will not be repeated in full here.

The foundation for the diagnosis and monitoring of injured patients is in adequate clinical examination skills. Basic equipment for the diagnosis of life-threatening injuries and the monitoring of vital signs include stethoscope, blood pressure (BP) cuff, pocket torch and thermometer, all of which are considered essential at all levels of the health care system. Foetal stethoscope and urinary catheter with collection bag for the measurement of urinary output are essential at all hospital levels. Various forms of electronic monitoring and invasive monitoring, such as central venous pressure (CVP), right heart catheters and ICP, add value to the management of severely injured patients and hence are deemed desirable. However, at this time, their costs prevent them from being considered essential. For more details on the preceding items, the reader is referred to a related WHO publication, Surgical care at the district hospital (26).

Plain-film radiography is essential at the upper two hospital levels and is highly desirable at GP-level hospitals. National plans may wish to designate it essential

TABLE 13 Diagnosis and monitoring

Resources

Facility level

Monitoring

Basic

GP

Specialist

Tertiary

Stethoscope

E

E

E

E

Blood pressure cuff

E

E

E

E

Torch (flashlight)

E

E

E

E

Thermometer

E

E

E

E

Foetal stethoscope

D

E

E

E

Urinary catheter with collection bag

D

E

E

E

Electronic cardiac monitoring

I

D

D

D

Pulse oximetry

I

D

D

D

Central venous pressure monitoring

I

D

D

D

Right heart catheterization

I

I

D

D

Intracranial pressure monitoring

I

I

D

D

Radiological investigations

Plain films

D

D

E

E

Portable plain films

I

D

D

E

Contrast radiography (barium, gastrograffin)

I

I

D

D

Ultrasound for trauma (haemoperitoneum)

I

D

D

D

CT1

I

D

D

D

Angiography

I

I

D

D

Image intensification/fluoroscopy

I

I

D

D

MRI2

I

I

D

D

Nuclear medicine

I

I

D

D

Laboratory tests

Haemoglobin/haematocrit

D

E

E

E

Glucose

I

E

E

E

Gram stain

I

D

E

E

Bacterial cultures

I

D

D

E

Electrolytes (Na, K, Cl, CO2, BUN3, creatinine)

I

D

D

D

Arterial blood gas measurements

I

D

D

D

Serum lactate

I

I

D

D

Other

Paediatric length-based tape (Broselow tape)

D

D

D

D

Otoscope

D

E

E

E

Opthalmoscope

D

D

E

E

Compartment pressure measurement

I

D

D

E

1 CT: Computerized axial tomography.

2 MRI: Magnetic resonance imaging.

3 BUN: blood urea nitrogen.

1 CT: Computerized axial tomography.

2 MRI: Magnetic resonance imaging.

3 BUN: blood urea nitrogen.

at GP hospitals that care for a specified minimum number of trauma cases. Given the importance of basic X-ray, the reader is referred to existing guidelines on the WHO Basic Radiology System (BRS) (49). The BRS describes the minimum equipment needed for basic X-ray services, oriented towards small hospitals.

The capability for portable plain X-rays (mobile radiography units) is deemed essential at tertiary care hospitals and desirable at all other hospitals. Other imaging capabilities, including CT scans, angiography, fluoroscopy, image intensification, MRI and nuclear medicine exams, add value to the management of injured patients. They are listed as desirable at various levels, as indicated in the table. Their costs prevent them from being designated essential at any level at this time.

Basic, general-purpose ultrasound is of great utility for non-trauma purposes, especially obstetrics. Hence, one might reasonably wish to assure its availability at all specialist and tertiary hospitals, as well as many GP hospitals, for general purposes. However, ultrasound for trauma requires more advanced skills in both performance and interpretation, primarily for the diagnosis of haemoperitoneum. It is this skill and capability that are considered desirable (rather than essential) at all hospital levels. See also section 5.7 (Management of abdominal injury) for more details.

The measurement of haemoglobin concentration or haematocrit by any suitable, reliable technique is deemed essential at all hospital levels, as is the measurement of serum glucose concentration. Gram stains are essential at specialist and tertiary hospitals. Bacterial cultures are essential at tertiary facilities. Measurements of electrolytes, arterial blood gases (ABG) and serum lactate are deemed desirable. Their costs prevent them from being deemed essential at any level at this time.

The use of a paediatric length-based tape (Broselow tape) is of benefit in the calculation of doses of fluids and medications for children. This is inexpensive and desirable at all institutions that care for injured children. Opthalmoscopes and otoscopes are useful adjuncts for the physical diagnosis of injured patients and are deemed essential or desirable as indicated in the table. Equipment for the measurement of compartment pressures can be purchased as a ready-made set or can be constructed using tubing and the gauge from a blood pressure cuff. Expertise to use either one is deemed essential at tertiary care facilities.

Any capabilities for monitoring, radiology or laboratory services that are deemed essential or that are converted from desirable to essential in a national plan should meet certain criteria, in addition to mere physical availability of the relevant equipment. These include prompt availability (24 hours a day, 7 days a week, if indicated), sufficient personnel skilled in performing the procedures or tests safely and accurately and in interpreting the results, and, where relevant, sufficient quality assurance mechanisms to monitor the application of the test or procedures. Diagnostic imaging and laboratory facilities should follow WHO

guidelines, including those for internal quality control and external quality assessment (http://www.who.int/eht/Main_areas_of_work/DIL/About_DIL.htm).

Equipment should be maintained so as to assure the availability of the related services without interruption due to malfunction. This point is to be emphasized, as the ability to manage and maintain medical equipment has often lagged behind acquisition of the equipment (49).

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