•Consider atypical presentation for ACS in elderly patients
•Risk factors for severity of acute pancreatitis include advanced age, obesity, organ failure, and pleural effusion
•Can use APACHE II score to risk stratify in the ED
•Blunt aortic injury (BAI) is a rare but often deadly entity
•Consider in all cases with significant mechanism
•Can have atypical/no symptoms or have distracting injury
•Management of BAI includes permissive hypotension and rapid transfer to the operating room
-- clamp with hemostat for 2 minutes;
-- using crush mark from hemostat;
-- perform lateral canthotomy with scissors perpendicularly
-- dissect inferiorly and snip the inferior crus of the lateral canthal tendon
-- recheck IOP after procedure
Case #1 (minor TBI + discussion about clinical decision rules [CDR]) – SLIDE #30
· GCS 15 ≠ 14 ≠ 13
· Know what each CDR gets you
· Pick a rule and use it (ATLS prefers Canadian, ACEP prefers New Orleans, Gibbs prefers Canadian)
· Be cautious with the intoxicated patient (Canadian only 70% sensitive… must achieve clinical sobriety 1st)
Case #2 (TBI on warfarin) – SLIDE #49
· Very high risk… be liberal with imaging
· No CDR to identify the low-risk patient
· Order INR on arrival
· Reversal of anticoagulation = resuscitation!
Case #3 (severe TBI) – SLIDE #94
· RSI with neuroprotective drugs
· Hyperosmolar therapy with either hypertonic saline or mannitol
· Do not hyperventilate unless there is clear clinical evidence of herniation
Trauma Resuscitation: Not ACLS
It's Not Always Sepsis!
1) Respect the elderly, but especially in geriatric trauma!
-Many of these patients are beta blocked and anticoagulated
-High risk for occult fracture, higher risk for mortality following any trauma
-Remember to apply geriatric trauma scoring, and triage conservatively
2) Don't fear the chronic tracheostomy patient in respiratory distress
-Remember your airway toolbox, gauge how much time you have!
-A NG tube can be a great placeholder for trach exchange
-Never forget you can (usually) still intubate these people from above
-Fiberoptic nasotracheal intubation as a failsafe
3) Consider imaging of the hip in pediatric leg pain
-SCFE can present as subacute knee pain, patients may still be able to walk!
-Consider in both boys and girls, obese and average sized
-Low threshold for imaging of the hips with knee or thigh pain complaints
4) Ensure you examine every trauma patient's eyes, checking for ocular trauma
-Globe rupture requires immediate optho consultation
-Do not perform further exams until this is ruled in or out
-Hyphema is a collection of blood in the anterior chamber, usually traumatic
-More anterior chamber filling associated with worse visual recovery
-Emergent consultation with opthomology, elevate head of bed, check for coagulopathy
Sneaky Ectopic - Dr. Nichols
GIB and Aortic Graft - Dr. Beverly
Pulmonary embolism + pleural effusion - Dr. West
Traumatic Ptx, Be Kind - Dr. Robertson
- Hypothermia: Can cause significant physiologic disturbance, generally starting when body temperatures fall beneath 90 degrees (moderate hypothermia). Moderate hypothermia should be aggressively corrected with both external and internal warming measures. Risk of refractory VFIB increases as you approach 82.4degrees.
- Severe hypothermia requires invasive rewarming techniques including invasive catheters (think therapeutic hypothermia in reverse). This can include hemodialysis and ECMO.
- Peri-intubation hypothermia: associated with increased risk of mortality as well as increased ICU and hospital length of stay. Take steps to avoid it! Think ketamine, fluids, pressors.
- Spinal shock: sudden vasoplegia caused by loss of output from sympathetic system. Classic presentation of hypotension and bradycardia is seen in less than 25% of cases. Most recent guidelines recommend norepinephrine as pressor of choice. Seen mostly commonly in injuries above T6.