Missed Dialysis & Syncope
- PR prolongation, QRS widening - can be a full block
- Sine wave
RUQ Abdominal Pain
**** Can have ectopic pregnancy with declining beta****
Missed Pubic Rami Fracture
**** Fully examine your patients and document well & make sure to reassess****
Surgical Setting: HTN, DM, Crush injury, open fracture, peripheral artery disease.
Staph Aureus Infections
- Hospital acquired infections relatively stable over the past 5 years
- Community acquired infections on the rise
- One ED visit increases risk 4-fold - Protect your patients!
- Patients on hemodialysis have a 50-180 fold increased risk for developing infective endocarditis
… be wary the vague presentation of endocarditis!
- Protect without pressure!
- Prevent vomiting/valsalva
- Don’t forget your tetanus
- Avoid ultrasound (just don't tell Dr. Tayal)
- Potassium is not the only electrolyte that causes rhythm disturbances
- When facing new EKG changes, consider magnesium and calcium
Type & Screen
- cheaper and doesn't hold blood and doesn't do whole cross match
- Consider in severe mechanisms, blood loss, tachycardia, concern for intraabdominal injury
Type & Cross
- holds blood
- Consider in coagulopathy & severe trauma; significant mechanism with known blood loss; base deficit < -6, lactate > 4, low Hgb; +FAST
- not routinely used
- consider in pelvic fractures (q1hr)
- WBC rarely useful;
- Consider to use to look at platelets (head trauma, liver disease, long bone Fx);
- For liver disease or anticoagulated;
- Get coags for severe head trauma
- Strongly associated with blood loss and mortality in the setting of trauma
- adult patient not in shock - gross hematuria matters;
- microscopic hematuria - in stable patients don't worry;
- in adult patients with shock - get CT scan - marker for intraabdominal injury;
- in pediatric population with microscopic hematuria - need CT scan - marker for intraabdominal injury - most commonly splenic injury
Special Trauma COnsiderations
- CPK now and at 4 hrs
- get PT/INR and lactate > 2 is concerning
- UA, LFT, lipase, Hgb
- serial pancreatic enzymes
Case 1: Inferior shoulder dislocation and traumatic pneumothorax
When Evaluating Complex Patients:
- Always regroup and reassess. It is okay to start over from scratch.
- Ensure work up is complete for life threatening pathology before patient leaves the ED
Inferior Shoulder Dislocation:
- High incidence of vascular and nerve injury. You must document a thorough exam!
- Reduction via hyperabduction with traction-counter traction or convert to anterior dislocation and then reduce.
Occult Traumatic Pneumothorax (i.e. visible on Chest CT but not on supine CXR):
- Supine CXR has sensitivity of ~50%
- Supine Ultrasound has sensitivity of ~90%. We should be doing FAST with thoracic windows on all patients, especially those with no plans for CT Chest
- Know/ Reference our trauma guidelines!
- No hard and fast guidelines in regards to management. Needs a chest tube if progresses (visible on CXR or if patient has respiratory distress).
- Most still feel positive pressure ventilation with occult PTX deserves a chest tube... although debated.
Case 2: Black Dot Poison Ivy
- Treat contact dermatitis with high potency topical steroid (ex. Clobetasol) for 2 weeks.
- If treating with PO steroids remember needs tx for 2-3 weeks with taper.
- Don’t forget adjuncts: Zanfel, Ivy Block (Research supports usage of both).
Case 3: Hx of Devic disease with missed posterior circulation stroke
- Know your limitations and don’t develop tunnel vision.
- A thorough CN II exam involves visual acuities, visual fields, light reflex and color testing.
- Optic neuritis typically has pain with eye movement (92%) and impaired color vision (Red first).
THE TRAUMA CAPTAIN CAN HAVE A BIG IMPACT!
-Good trauma rescucitation can have large impact on outcomes
-Good rescuc should be organized, quiet, and rapid
-Simulation important, ATLS compliance increased 56% to 83%, procedure completion time reduced
-Review and understand the established protocols for trauma
Before a CODE
-Check code criteria and establish if appropriate personnel present
-Assign roles: airway, procedures, ultrasound.
-Anticipate possible procedures and prepare drugs/equipment
-Set expectations prior to arrival of pt - expected time to completion of code/rescucitation
-Be Loud and Calm
At the CODE
-Establish your leadership - "Everybody listen up"
-Move patient after medic report
-ABCs, primary and secondary survey, monitoring, lab studies
-Continually articulate the plan and ultimate disposition. "Why are we still here?"
-Feel them feet
-Where's the blood? External, chest, abdomen, thighs, retroperitoneum
-Pain control: Caution if shock, AMS, elderly
-No drama, quiet, can betray how sick they are
-Low reserve, normal VS until crash
-Get a lactate, liberal CT scanning
-Admit these patients
Pre-CT check list
-CT is a dark place where trauma patients go to die
-Before CT, do you Need ET tube? Chest tube? Pelvic binder? Tourniquet? Splints?
-Do they really need CT, or do they need OR, angiography, or transfer?
The Literature is Consistent
1. The NEXUS clinical decision rule (CDR) is effective in the elderly.
2. The NEXUS CDR is effective and in older children (>8 years). Because cervical injury is very rare in younger children (<8 years), use caution in this age group.
3. The new AANS recommendations (2013) do not recommend plain film imaging if CT is available.
4. In patients with spinal cord injury, maintenance of adequate tissue perfusion (e.g.: MAP 85-90) should be maintained for the first 7 days post-injury.
5. Steroids are no longer recommended in the treatment of acute spinal cord injury.
GU & Pelvic Trauma Basics
- Pelvic fracture, direct blow, penetrating injury - bladder rupture in 5-10% of pelvic fractures (more fractures = higher risk of injury)
- Intraperitoneal - dome is the weakest part (surgical repair)
- Extraperitoneal - manage with foley
Evaluation of the GU Tract
- Look for extravasation & look for contrast in bladder - if no contrast in the bladder = complete disruption of urethra - this requires surgery; some partial injuries can be managed with Foley catheter.
Upper Tract Injury
- flank bank or abdominal pain with gross hematuria or microscopic hematuria with shock
- 85% of renal injuries are secondary to blunt trauma;
- any penetrating trauma near this area requires evaluation of kidneys
- management depends on grade of injury
- Ureteral injuries - easy to miss; tend to present late
Pelvic Ring Fractures
- pelvis is strong - takes a lot of force to break it;
Assess for injuries:
a. Proximate - urethra, bladder, vagina, sciatic nerve
b. Distant - brain, chest, aorta, intra-abdominal
Who to image- physical findings suggestive of injury, shock
1. Lateral compression - horizontal anterior ring fracture- look for sacral fracture
2. AP - open book fracture - high risk of bleeding out - "mac daddy of pelvic fracture"
3. Vertical Sheer - high risk of vascular injury - if no femur fracture put in traction
4. Posterior ring disruption - increased mortality
Unstable patients with pelvic fracture
- angio vs OR: if grossly positive FAST, OR first. If not, angio first.