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.

CASE #1CASE #1

Crash em up... Crash em up...

18 yo belted male, MVC on 2 lane, rollover 2 18 yo belted male, MVC on 2 lane, rollover 2 a.m., car is all smashed up...a.m., car is all smashed up...

-Awake, GCS 15, HR=125, RR 14, BP 80/60 –”I -Awake, GCS 15, HR=125, RR 14, BP 80/60 –”I can’t move my arms and legs….”can’t move my arms and legs….”

-Head atraumatic-Head atraumatic- Neck, chest/abd okNeck, chest/abd ok- Extremities atraumaticExtremities atraumatic

-Neuro exam – what do you want to know?-Neuro exam – what do you want to know?

Crash em up... Crash em up...

18 yo belted male, MVC on 2 lane, rollover 2 18 yo belted male, MVC on 2 lane, rollover 2 a.m., car is all smashed up...a.m., car is all smashed up...

-Awake, GCS 15, HR=125, RR 14, BP 80/60 -Awake, GCS 15, HR=125, RR 14, BP 80/60 –”I can’t move my arms and legs….”–”I can’t move my arms and legs….”

-Neuro exam – no motor function to lower or -Neuro exam – no motor function to lower or upper extremities, no sensory function upper extremities, no sensory function below neck.below neck.

Smash em up... Smash em up...

Arrive at Trauma Center:Arrive at Trauma Center:

3 liter IVF (1 prehospital, 2 in ED)3 liter IVF (1 prehospital, 2 in ED)

HR 125, BP 85/60 HR 125, BP 85/60

Still can’t move arms/legs…Still can’t move arms/legs…

Where’s the Where’s the blood?blood?

Chest…Abdomen…Pelvis…Thigh…Spine…Head...

CXRU/S FAST, CTPelvis XRThigh ExamSpine XR/CT, examHead exam, CT

Cervical AlignmentCervical Alignment

Anterior vertebral Anterior vertebral bodybody

Posterior Posterior vertebral bodyvertebral body

Spinolaminal lineSpinolaminal line

Spinous process Spinous process tipstips

Compression/Burst Compression/Burst fracturefracture

Where’s the Where’s the blood?blood?

Chest…Abdomen…Pelvis…Thigh…Spine…Head...

CXR NormalU/S: fluid!Pelvis XR NormalThigh exam okAbnormal neuro/XR!Norml exam

Manage Blood in Manage Blood in the Abdomen: the Abdomen:

Fluid, Blood, ORFluid, Blood, ORManage Neuro Manage Neuro

Shock:Shock:Pressors Pressors

(dopamine)(dopamine)

If he’s still If he’s still hypotensive: hypotensive:

OR!OR!If BP normalizes:If BP normalizes:

CT!CT!3 liters IVF….3 liters IVF….BP 95/60, HR BP 95/60, HR

110…110…

Where’s the Where’s the blood?blood?

Chest…Abdomen…Pelvis…Thigh…Spine…Head...

CXR NormalU/S: fluid! CT++Pelvis XR NormalThigh exam okAbnormal neuro/XRNorml exam

Crash em up... Crash em up... 18 yo belted male, MVC on 2 lane, rollover 2 a.m., 18 yo belted male, MVC on 2 lane, rollover 2 a.m.,

car is all smashed up...car is all smashed up...

-Awake, GCS 15, HR=125, RR 14, BP 80/60 –”I -Awake, GCS 15, HR=125, RR 14, BP 80/60 –”I can’t move my arms and legs….”can’t move my arms and legs….”

-Neuro exam – no motor function to lower or upper -Neuro exam – no motor function to lower or upper extremities, no sensory function below neck.extremities, no sensory function below neck.

Goes to the OR – remove the spleen.Stabilizes…..Neurosurg next – stabilize spineDischarge to a tough road ahead….

CASE #2CASE #2

56 yo male56 yo male-EMS Response for altered level of -EMS Response for altered level of consciousnessconsciousness-Chief complaint: alcohol detox & -Chief complaint: alcohol detox & suicidality….suicidality….Drinks every day, homeless…found in the Drinks every day, homeless…found in the gutter…..gutter…..

Negative review of systemsNegative review of systemsTransported to Emergency Department Transported to Emergency Department and Emergency Psychiatry for medical and Emergency Psychiatry for medical clearance to detoxclearance to detox

Meds: NoneMeds: None NKDANKDAPmhx: NegativePmhx: Negative

Exam: intoxicated, no signs of trauma, Exam: intoxicated, no signs of trauma, GCS=15GCS=15

Intoxicated, sobers up in the ED overnightIntoxicated, sobers up in the ED overnight

56 yo male56 yo male-EMS Response for altered level of -EMS Response for altered level of consciousnessconsciousness-Chief complaint: alcohol detox & -Chief complaint: alcohol detox & suicidality….suicidality….

Transported to Emergency Department Transported to Emergency Department and Emergency Psychiatry for medical and Emergency Psychiatry for medical clearanceclearance

Intoxicated, sobers up in the ED overnightIntoxicated, sobers up in the ED overnight8 a.m.: Psychiatrist consult to me….8 a.m.: Psychiatrist consult to me….““Trying to decide whether he should Trying to decide whether he should have a head CT, he’s been falling have a head CT, he’s been falling down a lot lately….”down a lot lately….”

Crocodile Hunter:Crocodile Hunter:The Early Years...The Early Years...

Future Career?Future Career?

When do When do we do a we do a Head CT?Head CT?

The Canadian CT Head Rule The Canadian CT Head Rule for Pts with Minor Head for Pts with Minor Head

InjuryInjuryThe Lancet 2001;357:1391-96The Lancet 2001;357:1391-96

New Orleans’ CT rule New Orleans’ CT rule published in 2000 New published in 2000 New England Journal Medicine.England Journal Medicine.

3121 Canadians to 10 large 3121 Canadians to 10 large Canadian hospitals.Canadian hospitals.

7.3

3.6 3.63.8

4.1

1.4

2.8

0

1

2

3

4

5

6

7

8

OR

OR of Abn CT

GCS<15 in EDSusp open or depr fxBasilar Sk FxVomiting>1Age >65Amnesia before injBad Mechanism

Lancet 01;357:1391-1396

Minor head inj = witnessed LOC, definite amnesia, or witnessed disorientationMinor head inj = witnessed LOC, definite amnesia, or witnessed disorientation

Basilar Skull Basilar Skull FXFX

Clinical DiagnosisClinical Diagnosis-Racoon’s Eyes-Racoon’s Eyes

-Hemotympanum-Hemotympanum-Battle Signs-Battle Signs

(Rhino/Otorrhea)(Rhino/Otorrhea)

New Orlean’s/Charity Criteria New Orlean’s/Charity Criteria

7 components:7 components:

HeadacheHeadache, Vomiting, age>60, , Vomiting, age>60, drug or Etoh drug or Etoh IntoxIntox, memory impairment, , memory impairment, trauma above the trauma above the

clavicles, seizure.clavicles, seizure. (No GCS, No (No GCS, No Mechanism)Mechanism)

Haydel: NEJM 2000;343:100-5 Haydel: NEJM 2000;343:100-5

Developing a decision Developing a decision instrument to guide CT instrument to guide CT

imaging of blunt head injury imaging of blunt head injury ptspts

J Trauma 2005;59:954-959J Trauma 2005;59:954-959

21 hospitals.21 hospitals. 13,728 Patients13,728 Patients 917 Injuries on CT (6.7%)917 Injuries on CT (6.7%)

Recursive partitioning: 8 CriteriaRecursive partitioning: 8 Criteria

Evidence of Skull FractureEvidence of Skull Fracture Scalp HematomaScalp Hematoma Neurologic DeficitNeurologic Deficit Altered Level of AlertnessAltered Level of Alertness Abnormal BehaviorAbnormal Behavior CoagulopathyCoagulopathy Persistent VomitingPersistent Vomiting Age > 65 YearsAge > 65 Years

Mower: J Trauma 2005;59:954-959 Mower: J Trauma 2005;59:954-959

- Unique to this study

Burton’s RulesBurton’s Rules: :

Vomiting, age>60, memory Vomiting, age>60, memory impairment, basilar skull or impairment, basilar skull or open/depressed, seizure, GCS open/depressed, seizure, GCS <15<15

+/?Loss of Consciousness and nothing else = No CT

Solution: Wear a Solution: Wear a HelmetHelmet

56 yo male56 yo male-EMS Response for altered level of -EMS Response for altered level of consciousnessconsciousness-Chief complaint: alcohol detox & -Chief complaint: alcohol detox & suicidality….suicidality….

Transported to Emergency Department Transported to Emergency Department and Emergency Psychiatry for medical and Emergency Psychiatry for medical clearanceclearance

Intoxicated, sobers up in the ED overnightIntoxicated, sobers up in the ED overnight8 a.m.: Psychiatrist consult to me….8 a.m.: Psychiatrist consult to me….““Trying to decide whether he should Trying to decide whether he should have a head CT, he’s been falling have a head CT, he’s been falling down a lot lately….”down a lot lately….”

Burton’s Rules for Head CTBurton’s Rules for Head CT: :

Vomiting, age>60, memory Vomiting, age>60, memory impairment, basilar skull or impairment, basilar skull or open/depressed, seizure, GCS <15, open/depressed, seizure, GCS <15, anything abnormal and a history anything abnormal and a history of alcoholismof alcoholism

+/?LOC and nothing else = No CT+/?LOC and nothing else = No CT

CASE #3CASE #3

54 year old male 54 year old male Right Hip Injury Right Hip Injury

History: Water Skiing – one ski, right leg History: Water Skiing – one ski, right leg Abduction injuryAbduction injury

PMHx: NonePMHx: None

Drugs: NoneDrugs: None Allergies: NoneAllergies: None

Exam: GCS=15, pulse ox = 96%; Exam: GCS=15, pulse ox = 96%; HR=115, BP =145/78HR=115, BP =145/78

Right hip and knee flexed – pain to right Right hip and knee flexed – pain to right hip.hip.

No other injury No other injury

54 year old male 54 year old male Right Hip Injury Right Hip Injury

History: Water Skiing – one ski, right History: Water Skiing – one ski, right leg Abduction injuryleg Abduction injury

- EMS - Fentanyl –multiple dosesEMS - Fentanyl –multiple doses - In the ED - MSO4 – 20 mg over In the ED - MSO4 – 20 mg over

multiple dosesmultiple doses

-XR: Fracture/Dislocation R hip.-XR: Fracture/Dislocation R hip.-

““Native” hip Native” hip dislocation dislocation

““Native” Hip Native” Hip DislocationDislocation

1) 1) Every hour that passes = 10% increase in Every hour that passes = 10% increase in ischemic necrosis of femoral head – not to ischemic necrosis of femoral head – not to be confused with PROSTHETIC Hip be confused with PROSTHETIC Hip DislocationDislocation

2) Many will not have a fracture – 2) Many will not have a fracture – only only dislocationdislocation

3) Reduction in hip = reduction in pain!3) Reduction in hip = reduction in pain!

4) Check for neurologic/vascular deficit4) Check for neurologic/vascular deficit

5)5) Immobilize and get moving! (to a Immobilize and get moving! (to a trauma center)trauma center)

54 year old male 54 year old male Right Hip Injury Right Hip Injury

History: Water Skiing – one ski, right History: Water Skiing – one ski, right leg Abduction injuryleg Abduction injury

-- In the ED Propofol for sedation… In the ED Propofol for sedation… very heavy sedation, multiple dosesvery heavy sedation, multiple doses

- Failed reduction attempts- Failed reduction attempts

- Reduced in the OR!- Reduced in the OR!

““Native” hip Native” hip dislocation dislocation

CASE #7CASE #7

Fell off the ladder… Fell off the ladder…

65 yom “workin on the roof….fell off the 65 yom “workin on the roof….fell off the ladder onto my left chest…broke my ladder onto my left chest…broke my ribs!”ribs!”

- Hurts when he takes a deep breath. No - Hurts when he takes a deep breath. No back/neck pain. No abdominal pain.back/neck pain. No abdominal pain.

- Exam: Vitals signs normal. No Exam: Vitals signs normal. No increased increased respiratory effort. respiratory effort. Normal breath Normal breath soundssounds

- Tender along left ribs – 9-10 …Tender along left ribs – 9-10 …Nontender abdomen…Nontender abdomen…

Left Chest Ribs:

Fractured/Contusion

Lung:Pneumothorax

Lung Contusion

Diaphragm:Ruptured Diaphragm

Spleen:Contusion/Fracture

Kidney:Contusion/Fracture

Large Bowel:Rupture/Contusion

Fell off the ladder… Fell off the ladder… 65 yom “workin on the roof….fell off 65 yom “workin on the roof….fell off

the ladder onto my left chest…broke the ladder onto my left chest…broke my ribs!”my ribs!”

- Hurts when he takes a deep breath. Hurts when he takes a deep breath. No back/neck pain. No abdominal No back/neck pain. No abdominal pain.pain.

Fractured spleen: observed til Fractured spleen: observed til hospital day 3 – discharged to hospital day 3 – discharged to followup.followup.

CASE #8CASE #8