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High-Risk Scenarios In Blunt Trauma: An Evidence- Based Approach - $30.00
Published: October 2011 (Volume 1, Number 3)
CME: This issue includes 3 AMA PRA Category 1 CreditsTM and 3 AOA Category 2A or 2B CME credits.
Authors
Michael A. Gibbs, MD, FACEP
Professor and Chief, Department of Emergency Medicine, Maine Medical Center, Portland, ME; Tufts University School of Medicine, Boston, MA
Robert J. Winchell, MD, FACS
Chief of Trauma Surgery, Maine Medical Center, Portland, ME; Associate Professor of Surgery, Tufts University School of Medicine, Boston, MA
Peer Reviewers
Michael Bessette, MD, FACEP
Chairman of Emergency Medicine, The Jersey City Medical Center, Jersey City, NJ
Kelly Gray-Eurom, MD, MMM, FACEP
Associate Chair / Associate Professor and Director of Business & Clinical Operations, Department of Emergency Medicine, University of Florida COM – Jacksonville, Jacksonville, FL
John M. Litell, DO
Chief Fellow, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
Mark Silverberg, MD, FACEP, MMB
Associate Residency Director and Assistant Professor, Department of Emergency Medicine, SUNY Downstate/Kings County Hospital, Brooklyn, NY
Abstract
Most injuries in the United States result from blunt mechanisms, including motor vehicle crashes and falls as well as from interpersonal violence. Patients who suffer severe blunt trauma typically experience a significant force vector, rapid deceleration, or both. Under these circumstances, multiple potentially life-threatening injuries are likely, requiring careful prioritization of diagnostic and therapeutic interventions. In the unstable patient with multisystem blunt trauma, a useful team strategy: (1) rapidly identifies the cause(s) of traumatic shock, (2) identifies and prioritizes “time-dependent” injuries in need of definitive therapy, and (3) orchestrates an immediate care plan that thoughtfully matches ongoing resuscitation with the identified injuries and the patient’s clinical course. This issue of EMCC will provide a logical “menu” for the rapid evaluation and management of traumatic shock. Three “high-risk” clinical scenarios will then be discussed: blunt aortic injury (BAI), pelvic ring fractures, and blunt abdominal trauma. These scenarios were chosen because of their lethality and call for complex decision making. The essentials of emergency department (ED) diagnosis and management will be reviewed for each.
Excerpt From This Issue
You are on duty at a community hospital ED when 2 patients arrive simultaneously after a high-speed crash between a pickup truck and a small sedan. Both patients were unrestrained. With the assistance of a partner and the on-call general surgeon, your ED team performs rapid assessments of both patients, with the following initial findings:
Patient 1 is the 33-year-old male driver of the pickup truck. The patient indicates that his chest struck the steering wheel, and he reports chest and back pain. He is restless and diaphoretic, his blood pressure reading is 95/72 mm Hg, and his pulse rate is 115 bpm. Upon examination, scattered contusions are observed on his chest and abdomen. The patient’s breath sounds are equal, and his abdomen is diffusely tender but not distended. He has no long bone fractures and no neurologic deficit. A supine chest x-ray reveals a wide mediastinum. (See Figure 1.) A pelvic x-ray shows no fractures; however, a FAST examination reveals free fluid in the Morison pouch and around the spleen. As a result of his persistent agitation, the patient is intubated.
Patient 2 is the 26-year-old male driver of the small sedan. He reports severe lower abdominal and pelvic pain and screams out with any movement of the backboard splint. His blood pressure reading is 84/60 mm Hg, and his pulse rate is 109 bpm. An examination reveals that the patient’s lungs are clear, his abdomen is diffusely tender, there is severe pain on pelvic compression, and he has an obvious closed fracture of the right tibia/fibula with preserved distal pulses and neurologic function. The results of a supine chest radiograph are normal, and a pelvic x-ray reveals an obvious fracture. (See Figure 2.) Results of a FAST examination are negative for free fluid in the peritoneum and pericardium.
Your facility has limited resources, and rapid decisions need to be made regarding stabilization and transfer. The team gathers to answer several important questions, including the following:
- Is additional ED testing needed?
- What are the essentials of ED stabilization?
- How should these 2 patients be prioritized for interfacility transfer?