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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.

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CASE #1

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  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

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