1 / 49

CASE #1

CASE #1. Crash em up. 18 yo belted male, MVC on 2 lane, rollover 2 a.m., car is all smashed up... -Awake, GCS 15, HR=125, RR 14, BP 80/60 –”I can’t move my arms and legs….” -Head atraumatic Neck, chest/abd ok Extremities atraumatic -Neuro exam – what do you want to know?. Crash em up.

huey
Download Presentation

CASE #1

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. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. CASE #1

  2. Crash em up... 18 yo belted male, MVC on 2 lane, rollover 2 a.m., car is all smashed up... -Awake, GCS 15, HR=125, RR 14, BP 80/60 –”I can’t move my arms and legs….” -Head atraumatic • Neck, chest/abd ok • Extremities atraumatic -Neuro exam – what do you want to know?

  3. Crash em up... 18 yo belted male, MVC on 2 lane, rollover 2 a.m., car is all smashed up... -Awake, GCS 15, HR=125, RR 14, BP 80/60 –”I can’t move my arms and legs….” -Neuro exam – no motor function to lower or upper extremities, no sensory function below neck.

  4. Smash em up... Arrive at Trauma Center: 3 liter IVF (1 prehospital, 2 in ED) HR 125, BP 85/60 Still can’t move arms/legs…

  5. Where’s the blood? Chest… Abdomen… Pelvis… Thigh… Spine… Head... CXR U/S FAST, CT Pelvis XR Thigh Exam Spine XR/CT, exam Head exam, CT

  6. Cervical Alignment • Anterior vertebral body • Posterior vertebral body • Spinolaminal line • Spinous process tips

  7. Compression/Burst fracture

  8. Where’s the blood? Chest… Abdomen… Pelvis… Thigh… Spine… Head... CXR Normal U/S: fluid! Pelvis XR Normal Thigh exam ok Abnormal neuro/XR! Norml exam

  9. Manage Blood in the Abdomen: Fluid, Blood, OR Manage Neuro Shock:Pressors (dopamine)

  10. If he’s still hypotensive: OR! If BP normalizes:CT! 3 liters IVF….BP 95/60, HR 110…

  11. Where’s the blood? Chest… Abdomen… Pelvis… Thigh… Spine… Head... CXR Normal U/S: fluid! CT++ Pelvis XR Normal Thigh exam ok Abnormal neuro/XR Norml exam

  12. Crash em up... 18 yo belted male, MVC on 2 lane, rollover 2 a.m., car is all smashed up... -Awake, GCS 15, HR=125, RR 14, BP 80/60 –”I can’t move my arms and legs….” -Neuro exam – no motor function to lower or upper extremities, no sensory function below neck. Goes to the OR – remove the spleen. Stabilizes….. Neurosurg next – stabilize spine Discharge to a tough road ahead….

  13. CASE #2

  14. 56 yo male -EMS Response for altered level of consciousness -Chief complaint: alcohol detox & suicidality…. Drinks every day, homeless…found in the gutter….. Negative review of systems Transported to Emergency Department and Emergency Psychiatry for medical clearance to detox Meds: None NKDA Pmhx: Negative Exam: intoxicated, no signs of trauma, GCS=15 Intoxicated, sobers up in the ED overnight

  15. 56 yo male -EMS Response for altered level of consciousness -Chief complaint: alcohol detox & suicidality…. Transported to Emergency Department and Emergency Psychiatry for medical clearance Intoxicated, sobers up in the ED overnight 8 a.m.: Psychiatrist consult to me…. “Trying to decide whether he should have a head CT, he’s been falling down a lot lately….”

  16. When do we do a Head CT? Future Career? Crocodile Hunter: The Early Years...

  17. The Canadian CT Head Rule for Pts with Minor Head InjuryThe Lancet 2001;357:1391-96 • New Orleans’ CT rule published in 2000 New England Journal Medicine. • 3121 Canadians to 10 large Canadian hospitals.

  18. Minor head inj = witnessed LOC, definite amnesia, or witnessed disorientation Lancet 01;357:1391-1396

  19. Basilar Skull FXClinical Diagnosis-Racoon’s Eyes-Hemotympanum-Battle Signs(Rhino/Otorrhea)

  20. New Orlean’s/Charity Criteria 7 components: Headache, Vomiting, age>60, drug or Etoh Intox, memory impairment, trauma above the clavicles, seizure.(No GCS, No Mechanism) Haydel: NEJM 2000;343:100-5

  21. Developing a decision instrument to guide CT imaging of blunt head injury ptsJ Trauma 2005;59:954-959 • 21 hospitals. • 13,728 Patients • 917 Injuries on CT (6.7%)

  22. Recursive partitioning: 8 Criteria • Evidence of Skull Fracture • Scalp Hematoma • Neurologic Deficit • Altered Level of Alertness • Abnormal Behavior • Coagulopathy • Persistent Vomiting • Age > 65 Years Mower: J Trauma 2005;59:954-959 - Unique to this study

  23. Burton’s Rules: Vomiting, age>60, memory impairment, basilar skull or open/depressed, seizure, GCS <15 +/?Loss of Consciousness and nothing else = No CT

  24. Solution: Wear a Helmet

  25. 56 yo male -EMS Response for altered level of consciousness -Chief complaint: alcohol detox & suicidality…. Transported to Emergency Department and Emergency Psychiatry for medical clearance Intoxicated, sobers up in the ED overnight 8 a.m.: Psychiatrist consult to me…. “Trying to decide whether he should have a head CT, he’s been falling down a lot lately….”

  26. Burton’s Rules for Head CT: Vomiting, age>60, memory impairment, basilar skull or open/depressed, seizure, GCS <15, anything abnormal and a history of alcoholism +/?LOC and nothing else = No CT

  27. CASE #3

  28. 54 year old male Right Hip Injury History: Water Skiing – one ski, right leg Abduction injury PMHx: None Drugs: None Allergies: None Exam: GCS=15, pulse ox = 96%; HR=115, BP =145/78 Right hip and knee flexed – pain to right hip. No other injury

  29. “Native” hip dislocation 54 year old male Right Hip Injury History: Water Skiing – one ski, right leg Abduction injury • EMS - Fentanyl –multiple doses • In the ED - MSO4 – 20 mg over multiple doses -XR: Fracture/Dislocation R hip.

  30. “Native” Hip Dislocation 1) Every hour that passes = 10% increase in ischemic necrosis of femoral head – not to be confused with PROSTHETIC Hip Dislocation 2) Many will not have a fracture – only dislocation 3) Reduction in hip = reduction in pain! 4) Check for neurologic/vascular deficit 5) Immobilize and get moving! (to a trauma center)

  31. “Native” hip dislocation 54 year old male Right Hip Injury History: Water Skiing – one ski, right leg Abduction injury -In the ED Propofol for sedation… very heavy sedation, multiple doses - Failed reduction attempts - Reduced in the OR!

  32. CASE #7

  33. Fell off the ladder… 65 yom “workin on the roof….fell off the ladder onto my left chest…broke my ribs!” - Hurts when he takes a deep breath. No back/neck pain. No abdominal pain. • Exam: Vitals signs normal. No increased respiratory effort. Normal breath sounds • Tender along left ribs – 9-10 … Nontender abdomen…

  34. Left Chest Ribs: Fractured/Contusion Lung: Pneumothorax Lung Contusion Diaphragm: Ruptured Diaphragm Spleen: Contusion/Fracture Kidney: Contusion/Fracture Large Bowel: Rupture/Contusion

  35. Fell off the ladder… 65 yom “workin on the roof….fell off the ladder onto my left chest…broke my ribs!” • Hurts when he takes a deep breath. No back/neck pain. No abdominal pain. Fractured spleen: observed til hospital day 3 – discharged to followup.

  36. CASE #8

More Related