Trauma/ER

5 min
4. Young male, thrown 20 feet from bike by car, in ER. Neuro exam.
B: interpret and comment on c-spine film
4) Telephone call: you are doc in ER in remote community and a mother
has
phoned telling nurse she will only speak to MD. o/e: get her number
and
address right away. Kid was playing in grandmother's room and took
some BP
meds, no idea what kind, mother threw bottle out, quanitity unclear.
Kid
crying. Keeps asking you what to do, frantic. Mother gets scripts
filled at a
pharmacy in Ilderton. You need to calm her down, find out where she
is, send
ambulance. WRITTEN: List five things you would do when the child
arrived in
ER. What are three things you would monitor specifically as they
pertain to
poisoning? (or something like that). You find out a similar incident
happened
with the kid's sibling. Who do you call? What is you responsibility?
What do
you tell the mother?
Trauma (Closed Head Injury)
Surg
PEP: 2 Ix
2 Med Interventions
1. 30 year old male gets hit by a car and sustains a head injury. Brought to ER
hemodynamically stable. Do a focused neuro exam. You do not have to give a GCS
score.
Findings: in a collar, localizing to pain in all four limbs, not opening eyes, not
verbalizing. Any attempt to address ABCs was discouraged by the examiner. No signs of
basal skull fracture. Pupils, corneals and gag were normal. Peripheral reflexes were
normal. Has blood all over him.
Questions: CXR, pelvic x-ray and lateral c-spine xray are all normal. You are in a
peripheral hospital and must transfer him to a level 1 trauma centre as you suspect that he
has a closed head injury. Name two investigations you would do, four management steps
and three actions would you take prior to transferring.

10 min station
4. MANAGE AN EPIGASTRIC STABBING IN ER WITH A NURSE
2. MANAGE ACUTE MI IN ER WITH NURSE
55 yo male with retrosternal CP and diaphoresis - mx
ABCs
B:
Oxygen, SaO2
C:
ASA 160 mg to chew STAT
vitals: HR, BP in both arms (important for dissection), peripheral pulses
continuous cardiac monitoring
ECG STAT
troponin q6h x 3, CBC, lytes, BUN, Cr
CXR
D5W TKVO
secondary assessment once above present if patient stable:
CV examination including JVP, carotids, precordial examination
Respiratory exam, peripheral vascular examination
if ECG changes c/w angina and chest pain symptomatology not c/w aortic
dissection (sharp/tearing CP with radiation to back), treat as angina
unstable angina (new onset, at rest, more severe/freq/longer duration/post-MI),
treat as above and add:
NTG 0.3mg sl q5min x 3
beta blockers are first line if not contra-indicated (HR 50 - 60 is goal)
if cant use beta blockers can use CCB (amlodipine)
iv heparin
angiography once patient stable with view to PTCA/CABG
if 2 of following are true: pain >30 min, ECG changes, enzymes positive = AMI
oxygen
ASA 325mg chewed STAT, then daily
NTG sl x 3 to r/o unstable angina
beta blockers to reduce HR if not contraindicated, continue indefinitely
thrombolysis indications:
presentation within 12 hours of onset of symptoms
at least hour of ischemic pain and
any of following ECG changes thought to be acute
1mm or more ST elevation in at least 2 limb leads

1mm or more ST elevation in at least 2 chest leads

complete LBBB (new)
ACEi should be considered for all patients starting day 3 - 16 post-MI

1. Man in 20's fell off ladder 14 feet. Bruised over left anterior ribs. On table in c-collar.
Asking for pain relief. Manage.
1.
2.

Acute MI: manage with help of nurse

Fall from ladder: manage with help of nurse

1.
30 M presents with fall. Has bruise over L side of abdomen. In C-spine collar.
Vitals stable. Manage for 1o or 2o survey. DPL shows free fluid in abdomen. Likely
splenic rupture. Acute management.
SURGERY
2.
40 M inferior STEMI. Presents with CP initially, then has CP in ER with inferior
ST elevations. Treat medically and consider TNK. Question: if man wants to leave
AMA, what do you do? Acute management.
MEDICINE
\
2) 70 yo f brought in after collapsing in a shopping mall.
Unresponsive, GCS around 8. List of medications in purse given to you when you ask
for meds, includes dig and spironolactone. Give orders to nurse and manage in ER
setting. EKG shows complete heart block, HR 40. Pressure about 70 systolic.
Give her atropine .5 and HR comes up to 70. No problems with fluid bolus. She also has
a living will in her purse that says she doesn't want to be resuscitated, so you shouldn't
intubate her early (her sats are fine and there is no blood work back yet, including a dig
level). At nine minutes, the examiner asks you what you would do considering the will if
in front of you the ekg degenerates into vf. You never get a serum dig level back so I
didn't give digibind, but I treated this like a presumed dig toxicity exacerbated by
hypokalemia. The document is from a lawyer so I presume they want us to do nothing.
5) 30 yo m at home with wife, started to have severe nausea and
vomiting, she
called ambulance. EKG normal. Epigastric pain, Might have been
slightly
hypotensive. Manage and give orders to nurse. ABC, etc etc. On
questioning
you find out he drinks lots of etoh and has had pancreatitis in the

past. No
suggestion this is cardiac. He is in a lot of pain and simulating
epigastric
tenderness. I gave him some demereol, kept him NPO, etc etc. At nine
minutes:
pt's wife is on the phone asking for information. Ask the patient and
he
says, "She'll nag me about my drinking, tell her I have the flu". You
have to
respond to this.

Management of acute MI

Comatose Patient - Scream out orders and do physical examination

Orders in comatose patient
- O2 sat - O2 standing by via mask
- 2 large bore IV's - consider giving bolus 2L NS
- Cross and type for 4U of blood
- Accucheck
- Draw blood for CBC, lytes, BUN, Cr, glucose, PT, PTT, INR, tox screen,
amylase
- foley and NG tube if needed
- xrays if needed, ct scan etc.
Physical Examination - ABC's as always
1. Airway - first secure/immobilize the spine
- chin lift / jaw thrust
- sweep and suction
- oral/nasopharyngeal airway/intubation if needed
--> look for resp distress, failure to speak, dysphonia, conduct (agitation,
confusion, choking)
--> always reassess the airway because status can change
2. Breathing

-look - watch for chest movement, resp rate/effort, patient's color

- listen - auscultate for breath sounds and symmetry of air entry
- feel - feel for the flow of air, chest wall for crepitus, flail segments and sucking
chest wounds
- assess - tracheal position, neck veins, resp distress
3. Circulation
- check for pulse rate and rhythm, blood pressure
- LOC, skin color, temp, cap refill
- stop any major external bleeding, elevate bleeding extremity
4. Disability
- AVPU method (shout name --> sternal rub/pinch fingers)
- look at pupils
5. Exposure
- keep patient warm with a blanket
SECONDARY SURVEY
- AMPLE - allergies, medications, past med hx, last meal, events related to injury
- Head to toe survey - tubes and fingers in every orifice, splint fractures, look for
toxidrome, ORDER X RAYS!!!!
- neurological, abdomen and perineal exam
PEP scenarios in past
1. Tension pneumothorax - needle decompression and chest tube
2. One fixed/dilated pupil - management of raised ICP, do GCS (nb!!)
- 100% oxygen, intubate and hyperventilate to a pCO2 of 30mmHg, mannitol
1g/kg, raise head of stretcher
1) Headache history space occupying lesions

Pain
Onset: sudden
Precipitating: head injury
Palliating: meds
Aggravating: position, time, activity, stress
Quality different from previous headaches?
Quantity (?/10), wake from sleep
Radiation
Site
Temporal: ever had before, duration, worse in am, worsening

Associated symptoms

N, V, weakness, sensory disturbance

Constitutional fever, chills, weight loss, loss of appetite
Visual changes, jaw claudication, polymyalgia rheumatica
Aura, photophobia, phonophobia

Risk factors:
Age
Cancer, immunocomp
Family history aneurysms
HTN

PMH: migraines, aneurysms, meds ( analgesics, NTG, toxins-CO)

7) History of foot pain in diabetic who stepped on nail

Examine legs and feet

Wound clean, infected
Neuropathic foot
Dry, warm and pink with palpable pulses
Impaired DTR
Reduced pinprick, light touch and vibration sensation
Ulcers usually painless and plantar

Ischemic foot
Skin is shiny and atrophic with sparse hair
Cold to touch
Peripheral pulses absent
Ulcers painful heels and toes

14) Assessment of volume status

Vitals
HR, RR, BP postural changes?
Mental status
HEENT
Mucous membranes moist/dry?
JVP
Resp
Crackles and decreased A/E
CV
S3
Abdomen
hepatomegaly
Skin
Decreased warmth/turgor/dry axilla?
Dependent edema sacral, calves

29 yo man with fall from height, ankle and abdominal injury, focused hx and
physical
Address ABC with c-spine control
History
details of accident: when, how did it happen, how high, what did you land on
areas of pain aside from abdomen and ankle (spine, ribs, etc.)
associated symptoms: address abdomen first, then ankle if no other injuries
abdomen: pain, distension, hematuria, hip pain
ankle: open wounds (open #), able to weight bear
past medical history especially with respect to abdomen and ankle
medications, allergies
smoking, alcohol
last meal
Physical
vitals
chest exam
abdomen: inspect for wounds, palpate, percuss, auscultate BS +, RECTAL
pelvis: stability (compress on pelvis anteriorly, laterally and palpate
suprapubic area)
ankle: neurovascular status of legs, inspect for swelling, open wounds, check
for tenderness at knee, look, feel, move
PEP
4 indications for laparatomy: peritonitis, pneumoperitoneum (free air), gun
shot wound in abdomen, hemodynamic instability with no other source of
blood loss, evisceration, blood in NG tube
3 causes of distended abdomen: (air/blood/fluid) pneumoperitoneum,
hemorrhage, ascites, bowel obstruction
45 yo man struck by a car and knocked off his bicycle - primary
assessment, mgmt of tension pneumothorax
Primary assessment
Airway with c-spine control
is the airway patent? blood, edema, decreased LOC, teeth, dentures
can the patient protect airway? Decreased LOC, facial #, cough/gag
reflex
assess: look, listen (talking/stridor), feel facial skeleton
options:
1) jaw thrust/chin lift
2) suction for blood
3) pharyngeal airway: oral/nasal (for tongue)
4) endotracheal intubation with C spine control
5) cricothyroidotomy: will require tracheostomy later
Breathing

assess
look at chest wall (symmetry, cyanosis, accessory muscle use)
listen
feel: trachea, subcutaneous emphysema, rib fractures (AP, lat
compression)
O2 saturation, CXR
options
1) oxygen
2) chest tube: large 32, at the anterior axillary line in the 4 th or 5th
ICS
3) intubate if cannot oxygenate (pulmonary contusion on admission
CXR)
4) MONITOR: O2 sat, ABG, CXR (following chest tube insertion)
tension pneumothorax: tracheal deviation, distended neck veins,
absent breath sounds, hypotension
management: 10 to 12 gauge needle in the 2 nd ICS at the MCL
superior to the 3rd rib; then chest tube
Circulation
assess: Vitals, CNS status, Skin perfusion, Urine Output
type of shock: Septic, Neurogenic, Hypovolemic/hemorrhagic,
Obstructive, Cardiogenic, AnaphylactiK
options for management of hemorrhagic shock:
1) insert 2 large bore ivs (16 gauge)
2) normal saline/ringers lactate: run 2L wide open
3) then consider packed RBCs:
O positive for men
O negative for children and women of childbearing age
type specific: takes 10-15 minutes
crossmatched: takes 45 minutes
PEP
given X-ray: tension pneumothorax: tracheal deviation, collapsed lung
give 3 clinical findings of tension pneumothorax: as above
21 yo female found unresponsive by mother, prior hx of increasing ICP physical exam
Physical
address ABCDE
stat bloodwork
cocktail: thiamine, glucose, naloxone
general appearance: noggin (head injury), neck (meningismus), needles, eNt:
otorrhea, rhinorrhea, odours (fetor, DKA, alcohol)
vitals: HR, RR, BP, temp

skin
respiration: progressions of
1) Cheyne-Stokes (bilateral cerebral hemisphere dysfunction / CHF)
2) central neurogenic hyperventilation (midbrain - pons)
3) apneustic breathing - prolonged pause at end of inspiration (pons)
4) ataxic breathing (medullary)
eyes
pupils
movements: intact brain stem
oculo-cephalic reflex: move head in one direction and eyes
move to opposite
oculo-vestibular reflex: COWS
movements: conjugate tonic gaze (frontal eye fields push eyes to
opposite side)
eyes look towards frontal deficit
eyes look away from pontine deficit
think about increased ICP affecting CN VI (because longest course)
think about transtentorial herniation affecting ipsilateral CN III (because
compression)
motor
asymmetry
spontaneous motor response
response to pain
decorticate: damage to hemispheres
decerebrate: damage to midbrain or upper pons
flaccid: damage to medulla
reflexes
verbal response

PEP
identify CN palsy ( III: down and out; VI: inability to abduct eye)
Significance of palsy: as mentioned above = III uncal herniation; VI increased
ICP
Assign GCS
Eye Opening
4 - spontaneously
3 - to speech
2 - to pain
1 - nil

Verbal Response
5 - oriented and
converses
4 - disoriented,
confused
3 - inappropriate words
2 - incomprehensible

Motor Response
6 - obeys
commands
5 - localizes pain
4 - withdraws to
pain
3 - decorticate

sounds
1 - nil

2 - decerebrate
1 - nil

Long term IDDM hypoglycemic periods with new job, charts with glucose
monitoring and insulin levels
cover manifestations of diabetes
macrovascular: accelerated atherosclerosis = CAD, stroke, PVD
microvascular: retinopathy, nephropathy, neuropathy (also autonomic)
meals, snacks, exercise
change insulin or lifestyle (activities)
past medical history
family history
medications, allergies
social: smoking, alcohol
While talking he passes out
hypoglycemia
symptoms: palpitations, sweating, anxiety, tremors
headache, fatigue, confusion, amnesia, seizures, coma
etiology
renal or hepatic failure
exogenous
drugs: insulin, oral hypoglycemics, alcohol
treat underlying cause
unconscious: give iv. D50W or if no iv. access, give glucagon IM
if conscious: give juice
PEP
management with chart: refer to previous scenario in terms of change in
treatment
diabetic coma: distinguish between hypoglycemia as above and DKA
start with ABCs
rehydration: calculate fluid deficit and replace deficit over 1 st 8 hours,
then rest over next 16 hours
potassium: monitor carefully and add potassium to iv if K < 5.5 and
patient is peeing
insulin: iv bolus 0.1-0.2 U/kg them maintain at 0.1 U/kg/hr until blood
glucose <15; then add glucose to iv solution and decrease insulin to 12 U/hr
bicarbonate: not recommended unless pH < 7.0
monitoring: glucose, lytes, anion gap, urea and creatinine q2hr