system trauma

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Johnny Blade; 27 4/5/1983

For Examiner Only

PHYSICAL EXAM

Patient Name: Johnny Blade Age & Sex: 27 yr old man

General Appearance: Ill appearing man, bleeding from the face, in full spine precautions

Vital Signs:BP 95/57 HR 132 Resp bagged T 99.0F O2 sat 96% with BVM FSBG 108 mg/dL

Primary Survey:-Airway: blood in oropharynx, dental trauma evident, no gag candidate should proceed tointubate-Breathing: (after intubation) good breath sounds bilaterally-Circulation: thready radial and femoral pulses, carotid pulses are normal. Two 16 gauge IVsplaced by EMS are working well.

Secondary Survey:Head: large(6 x 8 cm)abrasions to right face/cheek.

Eyes: pupils 4 to 3 mm but sluggish, corneal reflexes present. Right periorbital swelling and

ecchymoses

Ears: hemotympanum on left

Mouth: blood in mouth, dental fxs of inferior central incisors

Neck: in cervical collar, no crepitus or gross deformities/masses/hematomas

Skin: Diaphoretic; capillary refill greater than 3 seconds; slightly pale

Chest: clear lung sounds to auscultation bilaterally

Heart: tachycardic, regular, no murmurs

Abdomen: Soft; non-distended, and no rigidity; bowel sounds are decreased; no scars; no

masses; 10 x 8 cm ecchymosis and erythema to right flank and RUQ

Genito-Urinary: nl penis and scrotum

Extremities: nl except for right knee with obvious deformity (dislocated). Right foot is cool and

neither dorsalis pedis nor posterior tibialis pulses are palpable.

Rectal: no gross blood, nl tone

Pelvis: stableBack: Normal

Neurological: unresponsive with eyes closed; pupils 4 to 3 mm but sluggish, +corneal reflexes;

no vocalizations whatsoever; withdraws to painful stimuli

Other exam findings: (if specifically asked by candidate)

Bedside Emergency Department U/S (provide stimulus sheet #9) reveals free fluid in

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Morrisons Pouch, no PTX, and no pericardial effusion.

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For Examiner Only

STIMULUS INVENTORY

#1 Emergency Admitting Form

#2 CBC

#3 BMP

#4 Urinalysis

#5 Chest xray

#6 C-spine xray

#7 Pelvic xray

#8 R knee xray (post reduction)

#9 Abdominal Ultrasound/FAST exam

#10 Lactate

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For Examiner Only

LAB DATA & IMAGING RESULTS

Stimulus #2 Stimulus #5Complete Blood Count (CBC) CXR: nlWBC 15.2/mm3

Hgb 13g/dL Stimulus #6Hct 40% C-spine xray: nlPlatelets 420/mm3

Differential Stimulus #7

Segs 70% Pelvis xray: nlBands 1%

Lymphs 24% Stimulus #8Monos 4% Right knee xray (post-reduction):Eos 1% tibial spine fx

Stimulus #3 Stimulus #9Basic Metabolic Profile (BMP) Abdominal U/S: + free fluid in MorrisonsNa+ 143 mEq/L pouchK+ 4.2 mEq/L

HCO3 16 mEq/L Stimulus #10Cl- 109 mEq/L Lactate: 15.5 mEq/LGlucose 115 mg/dLBUN 16 mg/dL Verbal Reports

Creatinine 0.9 mg/dL PT / PTT / INR = INR 1.0Blood alcohol : NMA

All other tests arenormal and/or unavailable

Stimulus #4 Urinalysis (U/A)Color yellow, clearSp gravity 1.015Glucose negProtein negKetone negLeuk. Est. negNitrite negWBC 0-1/HPFRBC 10-15/HPF

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Learner Stimulus #1

ABEM General Hospital

Emergency Admitting Form

Name: Johnny Blade

Age: 27 years

Sex: Male

Method of Transportation: EMS

Person giving information: EMS personnel

Presenting complaint: Multi-vehicle freeway crash

Background: Patient was found on the shoulder of the 5 freeway, ejected 20 feet from his

motorcycle after striking a car involved in a multi-vehicle crash.

Triage or Initial Vital Signs

BP: 95/57 mmHg

P: 132/minute

R: being bagged

Pulse Ox: 96%

T: 99.0 rectally

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Learner Stimulus #2

Complete Blood Count (CBC)WBC 15.2/mm3

Hgb 13g/dLHct 40%Platelets 420/mm3

DifferentialSegs 70%

Bands 1%Lymphs 24%Monos 4%Eos 1%

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Learner Stimulus #4

Urinalysis (U/A)Color yellow, clearSp gravity 1.015Glucose negProtein negKetone negLeuk. Est. negNitrite negWBC 0-1/HPFRBC 10-15/HPF

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Learner Stimulus #5

Chest x-ray

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Learner Stimulus #6

C-spine x-ray

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Learner Stimulus #7

Pelvis x-ray

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Learner Stimulus #9

Abdominal Ultrasound/FAST exam

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Learner Stimulus #10

Lactate: 15.5 mEq/L

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Feedback/ Assessment Forms

Multi-System Trauma

Candidate ________________________ Examiner _________________________

Critical Actions:

Critical Action #1: Immediate intubation while maintaining C-spine immobilization

Critical Action #2: Perform a basic neurologic exam prior to giving paralytics

Critical Action #3: Aggressive IVF and blood product administration for hypotension/shock

Critical Action #4: Perform a FAST exam and recognize intraperitoneal hemorrhage Critical Action #5: Recognize and immediately reduce knee dislocation, verify pulses are

present after reduction

Critical Action #6: Obtain CXR, Pelvis XR, & C-spine XR in hemodynamically unstablemulti-trauma patient

Critical Action #7: Call the Trauma surgeon for immediate OR resuscitation. NO CTIMAGING!

Critical Action #8: Explain patients condition to the family in the waiting room

Dangerous Actions: (Performance of one dangerous action results in failure of the case)

Dangerous Action #1: Sending patient with + FAST exam & hemodynamic instability to CT

for further imaging Dangerous Action #2: Failure to recognize that patients BP is not responding to IVF alone

and requires blood products.

Overall Score:

Pass

Fail

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For Examiner

Date: Examiner: Examinee:Scoring: In accordance with the Standardized Direct Observational Tool (SDOT)

The learner should be scored (based on level of training) for each item above with oneof the following:

NI = Needs ImprovementME = Meets Expectations

AE = Above ExpectationsNA= Not Assessed

Critical Actions NI ME AE NA CategoryImmediate intubation whilemaintaining C-spine immobilization

PC, MK

Perform a basic neurologic examprior to giving paralytics

PC, MK

Aggressive IVF and blood productadministration for hypovolemicshock

PC, MK, PBL

Perform a FAST exam andrecognize intraperitonealhemorrhage

PC, MK, PBL

Recognize and immediately reduceknee dislocation, verify pulses arepresent after reduction

PC, MK

Obtain CXR, Pelvis XR & C-spineXR in unstable trauma patient

PC, MK, PBL

Call the Trauma surgeon forimmediate OR resuscitation. NO CTIMAGING!

PC, MK, ICS,SBP

Explain patients condition to thefamily in the waiting room

ICS, P

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Keywords for future searching functions:Blunt TraumaKnee dislocationHemoperitoneumFAST examHemorrhagic shock

References:Charles Gomersall 2010. http://www.aic.cuhk.edu.hk/web8/trauma%20basics.htm

Marx J. et al, editor. Rosens Emergency Medicine, Concepts and Clinical Practice, 5th edition.Chapter 4: Shock. Kline JA. Page 42. Mosby, Inc. St. Louis, Missouri, 2002.

Robert Reardon, MD.http://www.sonoguide.com/FAST.html

Rozycki GS, Ballard RB, Feliciano DV, Schmidt JA, Pennington SD.Surgeon-performed ultrasound for the assessment of truncal injuries: lessonslearned from 1540 patients.Ann Surg,1998;228:557-67.

Wherrett LJ, Boulanger BR, McLellan BA, Brenneman FD, Rizoli SB, Culhane J,Hamilton P.Hypotension after blunt abdominal trauma: the role of emergent abdominalsonography in surgical triage.J Trauma,1996;41:815-20.

Has this work been previously published?No, this case has not been published. A similar version of this case was used at my homeinstitution (University of California, San Diego) for our Emergency Medicine Residency Mockoral boards program.

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http://www.aic.cuhk.edu.hk/web8/trauma%20basics.htmhttp://www.sonoguide.com/FAST.htmlhttp://www.sonoguide.com/FAST.htmlhttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=9790345&ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSumhttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=8913209&ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSumhttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=8913209&ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSumhttp://www.aic.cuhk.edu.hk/web8/trauma%20basics.htmhttp://www.sonoguide.com/FAST.htmlhttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=9790345&ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSumhttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=8913209&ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSumhttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=8913209&ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum


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Debriefing Materials:

1.) Intubation in the setting of suspected cervical spine injury:

Manual In-Line Stabilization is used to stabilize the cervical spine while attempting orotrachealintubation.

Charles Gomersall 2010. http://www.aic.cuhk.edu.hk/web8/trauma%20basics.htm

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The provider holding C-Spine Immobilization fromthe head of the bed (afterparalytics) may assist theairway operator to improvevocal cord visualization byadding jaw thrust.Griswold, 2011.2.) Hemorrhagic Shock:Standard treatment forhemorrhagic shock inadults consists of rapidlyinfusing 2 liters of isotoniccrystalloid per ATLSrecommendations. Ifcriteria for shock persist

despite crystalloid infusion,PRBCs should be infused(5-10 ml/kg). Type-specificblood should be usedwhen the clinical scenariopermits, but uncrossmatched blood should be immediately used for patients with hypotensionand uncontrolled hemorrhage. O-negative blood is used in women of childbearing age and O-positive blood in all others.

Marx J. et al, editor. Rosens Emergency Medicine, Concepts and Clinical Practice, 5th edition.Chapter 4: Shock. Kline JA. Page 42. Mosby, Inc. St. Louis, Missouri, 2002.

3.) FAST Exam: FAST is an acronym for Focused Assessment with Sonography in Traumaand has become synonymous with beside ultrasound in trauma. The FAST exam, per ATLS

protocol, is performed immediately after the primary survey of the ATLS protocol. Ultrasound isthe ideal initial imaging modality because it can be performed simultaneously with otherresuscitative cares, providing vital information without the time delay caused by radiographs orcomputed tomography (CT). The concept behind the FAST exam is that many life-threateninginjuries cause bleeding. Although ultrasound is not 100% sensitive for identifying all bleeding, itis nearly perfect for recognizing intraperitoneal bleeding in hypotensive patients who need anemergent laparotomy.

Robert Reardon, MD.http://www.sonoguide.com/FAST.html

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http://www.sonoguide.com/FAST.htmlhttp://www.sonoguide.com/FAST.htmlhttp://www.sonoguide.com/FAST.html

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