cc i think i need stitches n.
Download
Skip this Video
Loading SlideShow in 5 Seconds..
PowerPoint Presentation
Download Presentation

Loading in 2 Seconds...

play fullscreen
1 / 14

- PowerPoint PPT Presentation


  • 77 Views
  • Uploaded on

CC: “I think I need stitches”. A Case of Head vs. Bat. EM Sub-I Presentation Kathy Staats , MS IV. HPI & ROS. 25 M brings self to ED one hour post blow to the head with aluminum baseball bat. Pt hit once on head Deflected another attempt w/left hand.

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about '' - barton


Download Now An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
cc i think i need stitches

CC: “I think I need stitches”

A Case of Head vs. Bat

EM Sub-I Presentation

Kathy Staats, MS IV

hpi ros
HPI & ROS
  • 25M brings self to ED one hour post blow to the head with aluminum baseball bat.
  • Pt hit once on head
  • Deflected another attempt w/left hand.
  • Pt denies loss of consciousness or memory/ dizziness/ lightheadedness/ change in vision or hearing/ tinnitus/ nausea/ vomiting/ difficulty or change in breathing.
hpi continued
HPI continued
  • Pt reports HA 8/10 throughout head
  • “Extreme pain” around laceration
  • Pt reports minimal tearing of

the eyes and a runny nose

  • ROS otherwise unremarkable
  • Pt reports most recent tetanus

shot in 10/2011

  • PMH: Pt denies history of concussion, surgeries, or chronic conditions.
  • NKDA. No current medications.
  • SH: Social smoker and drinker
physical exam
Physical Exam
  • V/S: 144/89 76 bpm16rpm99%RA98.8°F
  • Gen: Well-nourished male, A&Ox3
  • HEENT: 2-inch, non-bleeding linear laceration above left eyebrow with 0.5-inch lac perpendicular to the major injury. Laceration extends to intact galea.
  • No battlesign/raccoon eyes.

No fluid from ears, no gross

crepitusor step-off of skull or

vertebrae. EOMI, MMM, PERRL,

ø JVD, øLAD

slide5

Neuro: CN II-XII intact. Grossly normal gait. 5/5 strength in all limbs. Sensation present & similar in all limbs. Negative Romberg’s test.

  • Extremities: Point tenderness on dorsal hand surface of left thumb. Decreased ROM in all directions.

3/5 Strength of thumb.

  • CV/Pulm/GI: RRR nl S1S2,

CTA B/L, +BS, -TTP

what should we do next
What should we do next?
  • For Focused Trauma:
    • Always ABCs
    • Disability and Neuro
    • Exposure
  • For Scalp Lacerations:
      • History
      • PE
      • Imaging and Consults –
        • Contrast or No?
        • Who and Why?
      • Wound Debridement & Repair
nexus criteria
Nexus Criteria

NSAID (N with N)

  • Neuro Deficit
  • Spinal Tenderness
  • Altered LOC
  • Intoxication
  • Distracting Injury

If NOT present, NO radiography

Sn: 97-100% Sp: 13%

canada c spine rule 3 parts
Canada C-Spine Rule: 3 Parts!
  • Age ≥ 65
  • Extremity Paresthesias
  • Dangerous Mechanism

1

If present, do radiography

If not, onto 2

  • Sitting in ED
  • Ambulating ever
  • Delayed neck pain
  • Rear end MVC
  • No c-spine tenderness

2

If present, onto 3

If not, onto x-ray

3

  • < 45° L or R = x-ray
  • Full ROM = cleared c-spine!
  • Test active ROM

Sn: 91% Sp: 37%

new orleans criteria shave me a bove the clavicle
New Orleans Criteria:SHAVEMeAbove the Clavicle
  • Seizure
  • Headache
  • Age > 60
  • Vomiting
  • Etohor Drug Intoxication
  • MEmory: Persistent anterogradeamnesia
  • Above the Clavicle-Visible Trauma

Sn: 100% Sp: 52%

canada criteria ff g damn
Canada Criteria: FF G DAMN
  • Fracture: Suspected open/depressed skull fracture
  • Fracture : Suspected basilar skull fracture
  • GCS < 15 at 2 hours post-injury
  • Dangerous Mechanism
  • Age ≥ 65
  • Memory: Retrograde amnesia from event ≥ 30 min
  • N/Vomiting ≥ 2 episodes

Sn: 100% Sp: 88%

hospital course
Hospital Course
  • Case discussed w/attending. Plan to CT head, and suture and release if benign read.
  • Hours later, CT has not been read and radiology cannot be reached. Next shift attending reviews CT w/medical student and no abnormalities are noted. Pt is sutured and prepared for discharge.
suturing
Suturing
  • Lidocaine w/epi on face (before irrigation):
    • Max dose 7 mg/kg ≈ Given 4 ml locally
    • 2 ml as nerve block in supraorbital notch
  • How much water & what kind for irrigation?
    • 60 ml/cm ≈ 240 ml of clean H2O (NaCl, tap, etc)
  • Sutured inner & outer layers:
    • 5 stitches with 4.0Vicryl on inner layer,
    • 16 stitches with 5.0 Nylon on skin
    • Can be left open to air, cleaned with soap and water
  • When to come back/why to come back
                  • 5days post forehead lac for removal & f/u
slide13

Original attending of case reviews CT

  • “Mildly depressed fracture anterior wall left frontal sinus. Soft tissue defect of left frontal scalp.”
  • ENT is consulted, but pt leaves AMA prior to exam.
  • Nine days later pt returns to ED for suture removal. Laceration is healing well, with no swelling/ erythema or associated pain.
  • - ROS, no HA/dizziness/

lightheadedness/rhinorrhea.

  • Appointment is scheduled

with ENT for following

day. Pt does not attend.

sources
Sources
  • "Assessment and Management of Scalp Lacerations." UpToDate. Web. 18 July 2012. <http://www.uptodate.com/contents/assessment-and-management-of-scalp-lacerations?source=see_link>.
  • "The New England Journal of Medicine." Validity of a Set of Clinical Criteria to Rule Out Injury to the Cervical Spine in Patients with Blunt Trauma — NEJM. Web. 18 July 2012.
  • Stiell, Ian G., et all. "The Canadian C-Spine Rule versus the NEXUS Low-Risk Criteria in Patients with Trauma." New England Journal of Medicine 349.26 (2003): 2510-518. Print.