Johnny Blade; 27 4/5/198 3

Actors (optional) 1. Roles patient, nurse, EMS providers, Trauma Surgeon 2. Who may play them oral board examiner or actors for simulation as below. a. Patient: High Fidelity Simulator or Standardized Patient b. Nurse: Best if this role is played by a nurse who works clinically in the ED or ICU, but can be played by resident / attending physicians, nurse educators, or very well trained actors c. EMS Providers: Can be played by actors, residents, medical students, or others d. Trauma Surgeon: Should be played by senior resident or attending physician 3. Action Role EMS: give additional history. RN: carry out orders. Surgeon: take patient to OR emergently. Further details below for simulation cases. a. Patient: Unresponsive b. Nurse: Helpful, does not mislead participants, does what participants ask him/her to do, clarifies all doses of medications and rates of infusions. Mediocre ED nurse. c. EMS Providers: Gives basic report upon arrival. Answers additional questions when asked. d. Trauma Surgeon: For novice learners, trauma surgeon asks if they think the patient needs a CT first, when they answer no, he takes the patient to the OR. Option for advanced learners - trauma surgeon can be cantankerous, doesnt want to take the patient to OR immediately, requesting or demanding CT scan of the patient first.

Johnny Blade; 27 4/5/198 3 For Examiner Only

Author: Anthony J. Medak, MD Case Title: Multi-System Trauma CASE SUMMARY CORE CONTENT AREA Trauma, Orthopedics SYNOPSIS OF CASE This is a trauma patient who presents after a high velocity motorcycle crash. He is critically ill upon presentation and needs several immediate procedures for stabilization. Including intubation, IVF resuscitation and blood products, as well as reduction of a knee dislocation with neurovascular compromise. There are no diagnostic challenges in the case, if the candidate follows basic ATLS guidelines. SYNOPSIS OF HISTORY The patient was part of a multiple car pile up on a nearby highway. Other victims are at various local Trauma Centers. He was wearing a helmet, and broadsided a vehicle as it made a rapid lane change to avoid another vehicle. The patient was ejected from his motorcycle, landing on the shoulder of the road in some brush. He was minimally responsive on scene, but EMS was unable to obtain a definitive airway. One victim was pronounced dead at the scene. No family or PMH are available during the initial stages of the case. SYNOPSIS OF PHYSICAL Physical exam findings are not subtle in this case. Dental trauma and blood in airway, as well as decreased level of consciousness require intubation. Hemotympanum is noted on the left. He is very tachycardic, pulses are thready. Abdomen is soft, but a large ecchymosis over the right flank is evident. Right knee is grossly deformed and is obviously dislocated. The right DP and PT pulses are not palpable. The foot is cool with delayed cap refill. CRITICAL ACTIONS 1. Immediate intubation while maintaining C-spine immobilization 2. Perform a basic neurologic exam (pupils, corneal reflexes, withdrawal to pain) prior to giving paralytics 3. Aggressive IVF and blood product administration for hypotension/shock 4. Perform a FAST exam and recognize intraperitoneal hemorrhage 5. Recognize and immediately reduce R knee dislocation, verify pulses are present after Reduction 6. Obtain CXR, Pelvis XR, & C-spine XR in hemodynamically unstable multi-trauma patient 7. Call the Trauma surgeon for immediate OR resuscitation. NO CT IMAGING! 8. Explain patients condition to the family in the waiting room Reviewer:

Johnny Blade; 27 4/5/198 3

For Examiner Only

CRITICAL ACTIONS SCENARIO BRANCH POINTS/ PLAY OF CASE GUIDELINES 1. Critical Action: Immediate intubation while maintaining C-spine immobilization This critical action is met by the candidate's quick recognition that the patient is obtunded and has blood in his airway. The examiner may use their discretion and make the intubation difficult, easy, etc. based on how the candidate is performing thus far. Cueing Guideline: A medical student may ask Should I hold his neck while you intubate? 2. Critical Action: Perform a basic neurologic exam prior to paralytics This critical action is met by the candidate's performing a rudimentary neurologic exam prior to paralyzing him for RSI. This is accomplished by assessing the pupils and assessing his response to painful stimuli, and can also include checking for corneal reflexes, gag, etc. Cueing Guideline: A nurse may ask: Whats his GCS? or What are his pupils like? just prior to intubation 3. Critical Action: Aggressive IVF and blood product administration for hypotension/shock This critical action is met by the candidate's rapid recognition of hypotension due to hypovolemic shock. Therapy should begin with isotonic IVF, then when minimal improvement is noted, should progress to blood products. Cueing Guideline: The nurse may ask: Doctor, hes not really getting much better with these fluids, do you want to give anything else? IF the participant still does not ask for blood, then the blood bank tech who is in the ED may ask Doctor, will you be needing any blood? 4. Critical Action: Perform a FAST exam and recognize peritoneal hemorrhage

This critical action is met by the candidate's performing a rapid FAST exam with the ED U/S machine. In addition, the candidate must correctly interpret the positive U/S results. Cueing Guideline: The nurse may state: I wonder why hes not improving. Do you think hes still losing blood somewhere? IF the participant still does not ask for an U/S, a medical student may ask: How can we figure out where hes bleeding? IF the participant still does not ask for an U/S, the nurse may ask: Will you be needing the ultrasound during this case? 3

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For Examiner Only

CRITICAL ACTIONS (continued) 5. Critical Action: Recognize and immediately reduce R knee dislocation, verify pulses are present after reduction

This critical action is met by the candidate's recognition that the knee is grossly deformed (only if candidate does an extremity exam) and that the right foot perfusion is compromised. They should immediately give some analgesia and reduce the knee, followed by reassessing the pulses and perfusion in the right foot. The leg should then be immobilized.
Cueing Guideline: The nurse may ask: What do you think about his leg, is it broken? 6. Critical Action: Obtain CXR, Pelvis XR & C-spine XR in hemodynamically unstable multi-trauma patient This critical action is met by ordering a CXR, Pelvis XR, & lateral C-spine XR. Cueing Guideline: The nurse may state: Radiology would like to know if you want any plain films on this patient.

7. Critical Action: Call the Trauma surgeon for immediate OR resuscitation This critical action is met by the candidate's recognition and understanding of the U/S results. With this information, he/she must now contact the Trauma Surgeon and inform them of the need for an OR resuscitation. The candidate MUST NOT allow the patient to go to the CT scanner. Cueing Guideline: If the candidate is ordering CT imaging, the CT tech on the phone will ask: Is your patient stable enough to come to the CT scanner? 8. Critical Action: Explain patients condition to family in the waiting room This critical action is met by the candidate's asking if family has yet arrived. When they 4

Johnny Blade; 27 4/5/198 3 are present, the candidate should take the time to explain the patients condition and answer their questions. The candidate should be empathetic and respectful in his/her demeanor. Cueing Guideline: If the candidate does not ask about family, the Social Worker will say: Doctor, this patients family is now in the waiting room. They are very distraught and would like to speak with you.

For Examiner Only PLAY OF CASE GUIDELINES This is a critically ill motorcycle crash victim. He was a helmeted rider that struck another car at freeway speeds. He was ejected from his motorcycle and found 20 feet from his bike in some scrub brush along the freeway shoulder. Another driver involved in the crash was pronounced dead at the scene. EMS reports getting 2 large IVs but were unable to intubate. He was mildly hypotensive en route (SBP in the low 90-100 range). He has been unresponsive throughout transport. No known PMH. Police are calling to notify family at this time. The candidate needs to perform multiple life & limb saving interventions immediately in the ED, including intubation, administering IVF and blood products, and reducing the knee dislocation (and verify the improved perfusion of the foot after reduction). After initial stabilization, the candidate should perform a FAST exam and recognize hemoperitoneum. Xrays of the C-spine, chest, pelvis, and right knee should all be obtained.

Johnny Blade; 27 4/5/198 3 The candidate should frequently reassess indices of perfusion including urine output, as well as frequent BP monitoring (noninvasive or via arterial line). The candidate SHOULD NOT allow the Trauma surgeon, nurses, etc to convince him/her to send the patient to CT. If so, the patient will code in the scanner and not respond to any resuscitative efforts.
SCORING GUIDELINES 1. Score up if they ask EMS personnel to stay around, and obtain a detailed history from the EMS providers after the primary survey is complete 2. Score up if they intubate expeditiously; score down if they continue on to the secondary survey before intubating 3. Score up if they vocalize that they will maintain C-spine immobilization during intubation; score down if they do not 4. Score up if they use head injury specific medications for / with RSI (lidocaine, fentanyl, etc.) 5. Score up if they recognize clinical findings of ICH (obtundation, facial trauma and hemotympanum) 6. Score up if they reduce the knee dislocation and verbalize that angiography will be needed once he is stable

For Examiner Only

HISTORY Onset of Symptoms: Patient is a 27-year-old male brought in by Paramedics. He was a motorcycle rider involved in a multi-vehicle crash on a nearby highway. Patient broadsided a vehicle that made a sudden lane change in front of him. He struck the car on the drivers side, then was ejected from his bike. He was found ~20 feet away, on the freeway shoulder, in some scrub brush. He has been unresponsive. EMS was unable to intubate, but did get good IV access. He has been

Johnny Blade; 27 4/5/198 3

hypotensive (SBP range 90-100s) during transport. Police have contacted family and they are en route to hospital. Another driver in the crash was pronounced dead at the scene. Background Info: Chief Complaint: Past Medical Hx: Past Surgical Hx: Habits: Patient was found on the shoulder of a nearby highway, ejected 20 feet from his motorcycle after striking a car involved in a multi-vehicle crash. Unable to provide due to altered level of consciousness (LOC) Unknown Unknown Smoking: Unknown ETOH: Unknown Drugs: Unknown Unknown Unknown Unable to obtain due to altered LOC

Family Medical Hx: Social Hx: ROS:

Johnny Blade; 27 4/5/198 3 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 99.0 F O2 sat 96% with BVM FSBG 108 mg/dL

Primary Survey: -Airway: blood in oropharynx, dental trauma evident, no gag candidate should proceed to intubate -Breathing: (after intubation) good breath sounds bilaterally -Circulation: thready radial and femoral pulses, carotid pulses are normal. Two 16 gauge IVs placed 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: stable Back: 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

Johnny Blade; 27 4/5/198 3

Morrisons Pouch, no PTX, and no pericardial effusion.

Johnny Blade; 27 4/5/198 3 For Examiner Only

STIMULUS INVENTORY #1 #2 #3 #4 #5 #6 #7 #8 #9 #10 Emergency Admitting Form CBC BMP Urinalysis Chest xray C-spine xray Pelvic xray R knee xray (post reduction) Abdominal Ultrasound/FAST exam Lactate

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For Examiner Only

LAB DATA & IMAGING RESULTS

Stimulus #2
Complete Blood Count (CBC) WBC 15.2/mm3 Hgb 13g/dL Hct 40% Platelets 420/mm3 Differential Segs 70% Bands 1% Lymphs 24% Monos 4% Eos 1%

Stimulus #5
CXR: nl

Stimulus #6
C-spine xray: nl

Stimulus #7
Pelvis xray: nl

Stimulus #8
Right knee xray (post-reduction): tibial spine fx

Stimulus #3
Basic Metabolic Profile (BMP) Na+ 143 mEq/L K+ 4.2 mEq/L HCO3 16 mEq/L Cl109 mEq/L Glucose 115 mg/dL BUN 16 mg/dL Creatinine 0.9 mg/dL normal and/or unavailable

Stimulus #9
Abdominal U/S: + free fluid in Morrisons pouch

Stimulus #10
Lactate: 15.5 mEq/L Verbal Reports PT / PTT / INR = INR 1.0 Blood alcohol : NMA All other tests are

Stimulus #4
Urinalysis (U/A) Color Sp gravity Glucose Protein Ketone Leuk. Est. Nitrite WBC RBC yellow, clear 1.015 neg neg neg neg neg 0-1/HPF 10-15/HPF

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Johnny Blade; 27 4/5/198 3

Learner Stimulus #1 ABEM General Hospital Emergency Admitting Form Name: Age: Sex: Method of Transportation: Person giving information: Presenting complaint: Johnny Blade 27 years Male EMS EMS personnel 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: P: R: Pulse Ox: T: 95/57 mmHg 132/minute being bagged 96% 99.0 rectally

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Johnny Blade; 27 4/5/198 3

Learner Stimulus #2 Complete Blood Count (CBC) WBC 15.2/mm3 Hgb 13g/dL Hct 40% Platelets 420/mm3 Differential Segs 70% Bands 1% Lymphs 24% Monos 4% Eos 1%

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Johnny Blade; 27 4/5/198 3

Learner Stimulus #3 Basic Metabolic Profile (BMP) Na+ 143 mEq/L K+ 4.2 mEq/L HCO3 16 mEq/L Cl109 mEq/L Glucose 115 mg/dL BUN 16 mg/dL Creatinine 0.9 mg/dL

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Johnny Blade; 27 4/5/198 3

Learner Stimulus #4 Urinalysis (U/A) Color Sp gravity Glucose Protein Ketone Leuk. Est. Nitrite WBC RBC

yellow, clear 1.015 neg neg neg neg neg 0-1/HPF 10-15/HPF

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Johnny Blade; 27 4/5/198 3

Learner Stimulus #5 Chest x-ray

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Johnny Blade; 27 4/5/198 3

Learner Stimulus #6 C-spine x-ray

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Johnny Blade; 27 4/5/198 3

Learner Stimulus #7 Pelvis x-ray

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Learner Stimulus #8 Right knee 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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Johnny Blade; 27 4/5/198 3

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 unstable multi-trauma patient Critical Action #7: Call the Trauma surgeon for immediate OR resuscitation. NO CT IMAGING! 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 one of the following: NI = Needs Improvement ME = Meets Expectations AE = Above Expectations NA= Not Assessed

Critical Actions
Immediate intubation while maintaining C-spine immobilization Perform a basic neurologic exam prior to giving paralytics Aggressive IVF and blood product administration for hypovolemic shock Perform a FAST exam and recognize intraperitoneal hemorrhage Recognize and immediately reduce knee dislocation, verify pulses are present after reduction Obtain CXR, Pelvis XR & C-spine XR in unstable trauma patient Call the Trauma surgeon for immediate OR resuscitation. NO CT IMAGING! Explain patients condition to the family in the waiting room

NI

ME

AE

NA

Category PC, MK PC, MK PC, MK, PBL PC, MK, PBL PC, MK PC, MK, PBL PC, MK, ICS, SBP ICS, P

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Johnny Blade; 27 4/5/198 3

Category: One or more of the ACGME Core Competencies as defined in the SDOT PC= Patient Care
Compassionate, appropriate, and effective for the treatment of health problems and the promotion of health

MK= Medical Knowledge

Residents are expected to formulate an appropriate differential diagnosis with special attention to life-threatening conditions, demonstrate the ability to utilize available medical resources effectively, and apply this knowledge to clinical decision making

PBL= Practice Based Learning & Improvement Involves investigation and evaluation of their own patient care, appraisal and assimilation of scientific evidence, and improvements in patient care ICS= Interpersonal Communication Skills
Results in effective information exchange and teaming with patients, their families, and other health professionals

P=

Professionalism
Manifested through a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population

SBP= Systems Based Practice

Manifested by actions that demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value

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Keywords for future searching functions: Blunt Trauma Knee dislocation Hemoperitoneum FAST exam Hemorrhagic 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: lessons learned 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 abdominal sonography 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 home institution (University of California, San Diego) for our Emergency Medicine Residency Mock oral boards program.

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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 orotracheal intubation.

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

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The provider holding CSpine Immobilization from the head of the bed (after paralytics) may assist the airway operator to improve vocal cord visualization by adding jaw thrust. Griswold, 2011. 2.) Hemorrhagic Shock: Standard treatment for hemorrhagic shock in adults consists of rapidly infusing 2 liters of isotonic crystalloid per ATLS recommendations. If criteria for shock persist despite crystalloid infusion, PRBCs should be infused (5-10 ml/kg). Type-specific blood should be used when the clinical scenario permits, but uncrossmatched blood should be immediately used for patients with hypotension and uncontrolled hemorrhage. O-negative blood is used in women of childbearing age and Opositive 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 Trauma and 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 is the ideal initial imaging modality because it can be performed simultaneously with other resuscitative cares, providing vital information without the time delay caused by radiographs or computed tomography (CT). The concept behind the FAST exam is that many life-threatening injuries cause bleeding. Although ultrasound is not 100% sensitive for identifying all bleeding, it is nearly perfect for recognizing intraperitoneal bleeding in hypotensive patients who need an emergent laparotomy. Robert Reardon, MD. http://www.sonoguide.com/FAST.html

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