Crash, Bonk, Thud! (Trauma Case Studies) John Beuerle, M.D.
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1 Crash, Bonk, Thud! (Trauma Case Studies) John Beuerle, M.D.
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4 Case 1 (22 y.o. female, wakeboarding injury) Case 1 (22 y.o. female, wakeboarding injury) Arrives via EMS cc: left leg injury HPI: Patient was wakeboarding, hit a wave, and twisted her left knee. PMHx: asthma SocHx: Nonsmoker, but does hookah occasionally.
5 Case 1 (22 y.o. female, wakeboarding injury) Physical Exam: Vitals: 134/54, HR 79, RR 18, 99.2 F, 100% on RA Neck: no c-spine tenderness CVS: RRR Abd: soft and nontender Neuro: A&O x 3, no motor or sensory deficits Case 1 (22 y.o. female, wakeboarding injury) Physical Exam: Lower extremity exam: Case 1 (22 y.o. female, wakeboarding injury) Physical Exam: Left lower extremity exam: Arrived with left knee in a cardboard splint Left knee effusion Diffuse knee tenderness Any knee movement elicits pain No LE edema, no calf tenderness Normal tib/fib and ankle exam
6 Case 1 (22 y.o. female, wakeboarding injury) Xrays: Left knee: joint effusion present, no fractures Left femur and tib/fib: no fx Case 1 (22 y.o. female, wakeboarding injury) Diagnosis: Left knee sprain, possible cartilagenous injury Treatment: LLE placed in knee immobilizer Patient fitted for crutches Rx for pain medication Instructions for R.I.C.E. Follow-up with orthopedic surgery in 1-2 weeks Case 1 (Part 2) (22 y.o. female, wakeboarding injury) Patient returns to the ED the following day with worsening pain and numbness to the left lower leg and foot.
7 Case 1 (Part 2) (22 y.o. female, wakeboarding injury) Physical Exam: Cold left foot No sensation to light tough Unable to palpate pulses Consultation: Malpractice carrier Vascular surgeon Get a CT angiogram of the LLE. I m on my way in. Case 1 (Part 2) (22 y.o. female, wakeboarding injury) CTA shows: Popliteal artery with extensive intra-arterial thrombus Lack of arterial blood flow to the distal extremity Signs of tissue ischemia Case 1 (Part 2) (22 y.o. female, wakeboarding injury) Hospital Course: Patient taken directly to the O.R. by vascular surgeon. Extensive ischemic injury noted to the muscles and soft tissue of the distal lower extremity. Undergoes popliteal artery repair with saphenous vein graft, thrombectomy, and fasciotomies.
8 Case 1 (Part 2) (22 y.o. female, wakeboarding injury) Hospital Course (Day #5): Progressive lower extremity necrosis Case 1 (Part 2) (22 y.o. female, wakeboarding injury) Hospital Course: Patient was returned to the O.R. for above-knee amputation. Developed worsening SOB on hospital day # 8. CTA shows large PE. Started on IV heparin. Develops ARDS, sepsis, DIC, etc. Eventually recovers and is discharged to SNF on hospital day #42. Case 1 (Part 2) (22 y.o. female, wakeboarding injury) Discussion: Traumatic knee injury Severe pain Vascular injury!!! Diminished distal pulses and/or sensory deficits Knee dislocation is commonly associated with vascular and nerve injuries. Vascular injury, if missed, often leads to limb loss.
9 Case 1 (Part 2) (22 y.o. female, wakeboarding injury) Vascular and nerve injury after knee dislocation: a systematic review. (Medina, et. al.) Clin Orthop Relat Res., 2014 Sep; 479(9): patients with knee dislocations 171 patients (20%) sustained a vascular injury 25% of patients sustained nerve injury 80% of vascular injuries underwent repair 12% of vascular injuries resulted in amputation Case 1 (Part 2) (22 y.o. female, wakeboarding injury) Case 1 (Part 2) (22 y.o. female, wakeboarding injury) Physical Exam findings: Up to 50% of knee dislocations spontaneously reduce prior to ED arrival, so inspection of the knee may be normal. Many dislocations have associated fractures, so X- rays are important. In the absence of fracture, a thorough ligamentous exam is crucial. Varus or valgus instability in full knee extension is suggestive of a spontaneously reduced yet grossly unstable dislocation.
10 Case 1 (Part 2) (22 y.o. female, wakeboarding injury) Physical Exam findings: Coexistent peroneal nerve injury occurs in 25-35% of patients and must be ruled out. Most commonly manifests with decreased sensation at the first webspace with impaired dorsiflexion of the foot. Case 1 (Part 2) (22 y.o. female, wakeboarding injury) Case 1 (Part 2) (22 y.o. female, wakeboarding injury) Physical Exam findings (continued): Red flags for vascular injuries: Pain out of proportion to exam Diminished or absent pulses Expanding or pulsatile hematomas Palpable thrills Audible bruits Red flags for vascular injury warrant immediate surgical repair, which should not be delayed by diagnostic testing.
11 Ankle Brachial Index Ankle Brachial Index Ankle Brachial Index ABI < 0.9 is abnormal
12 Case 1 (Part 2) (22 y.o. female, wakeboarding injury) Disposition: Time is crucial! Vascular repair delayed more than 8 hours after injury carries an amputation rate of greater than 80%. In contrast, operative vascular repair within 8 hours of injury yields a limb-salvage rate of 80%. All knee dislocations not requiring immediate surgical revascularization should be admitted for serial perfusion checks, as delayed intimal flap thromboses, AV fistulas, and significant pseudoaneurysms can occur. Case 2 (24 y.o. male, s/p MVC)
13 Case 2 (24 y.o. male, s/p MVC) HPI: Reported LOC Patient amnestic to the event Reports mild SOB, chest and abdominal pain PMHx: none Rx: none SocHx: negative SurgHx: none Case 2 (24 y.o. male, s/p MVC) Physical Exam: Vitals: 118/52, HR 89, RR 20, 99% on RA Neck: no c-spine tenderness CVS: RRR Resp: diminished bilaterally, but CTA Abd: soft with diffuse tenderness Neuro: A&O x 3, no motor or sensory deficits Case 2 (24 y.o. male, s/p MVC)
14 FAST Exam (Focused Assessment with Sonography for Trauma) FAST Exam (Hepatorenal View: Morrison s Pouch) FAST Exam (Splenorenal View)
15 FAST Exam (Suprapubic View) FAST Exam (Subxiphoid View) FAST Exam (Parasternal View)
16 FAST Exam (Hemopericardium) FAST Exam (Pulmonary Views) FAST Exam (Pulmonary Views)
17 FAST Exam Case 2 (24 y.o. male, s/p MVC) Diagnostic Work-up: CXR CT studies Labs, UA EKG
18 Labs UA: normal UDS: negative BAL < 2
19 Case 2 (24 y.o. male, s/p MVC) Disposition: (a) Discharge home (b) Admit for observation (c) Consult a specialist (d) Invite patient to dinner (e) Both a and d are correct (f) Both b and c are correct (g) None of the above
20 Case 2 (24 y.o. male, s/p MVC) Return ED visit (later that evening): cc: Too many Heinekens. Physical Exam: Vitals: 92/42, HR 160, RR 14, 99% on RA CVS: tachycardic, regular rhythm Resp: CTA Abd: firm; diffusely tender Neuro: somnolent; difficult to awaken Case 2 (24 y.o. male, s/p MVC) Plan of action: (a) Ask the patient, Do you feel safe at home? (b) Repeat a CT scan (c) Repeat the FAST exam (d) Call the surgeon (e) Admit to the ICU and let the intensivist figure it out. (f) Discharge the patient home. He s a drug seeker if I ever saw one!
21 Case 2 (24 y.o. male, s/p MVC) Hospital Course: Patient taken to the O.R. Small bowel perforation repaired Admitted to the ICU Cardiology consultation AICD placement Patient discharged on hospital day # 6 Case 2 (24 y.o. male, s/p MVC) Discussion: Patients with a seatbelt sign are at increased risk for intra-abdominal injuries. Case 2 (24 y.o. male, s/p MVC) Seatbelt sign following blunt trauma is associated with increased incidence of abdominal injury. (Chandler, et. al.) Am Surg, 1997 Oct; 63(10): Retrospective review of 117 MVC patients Seatbelt sign (14 patients) 64% had an intraabdominal injury 36% required operative repair 21% had a small bowel perforation No seatbelt sign (103 patients) 8.7% had an intraabdominal injury 3.8% required operative repair 1.9% had a small bowel perforation
22 Case 2 (24 y.o. male, s/p MVC) Discussion: Patients with a seatbelt sign are at increased risk for intra-abdominal injuries. A negative CT does not rule-out bowel injury. Performance Patients with of blunt CT in abdominal detection trauma of bowel and injury. persistent (Butela, abdominal et. al.) pain warrant admission for further observation. AJR, 2001 Jan; 176(1): CT sensitivity of 64% in the diagnosis of bowel injury Case 3: 11 y.o. male, fell while skiing C R I T O E Ossification Centers of the Elbow
23 Case 3: 11 y.o. male, fell while skiing
24 Which elbow is fractured?
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26 Which elbow is fractured?
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30 Case 4 (4 y.o. male, elbow injury) Case 4 (4 y.o. male, elbow injury) Case 4 (4 y.o. male, elbow injury)
31 Case 4 (4 y.o. male, elbow injury) Case 4 (4 y.o. male, elbow injury) Case 4 (4 y.o. male, elbow injury) Pronation versus supination maneuvers for the reduction of pulled elbow : a randomized clinical trial. Bek, et. al., Eur J Emerg Med Jun;16(3): patients, randomized to supination-flexion vs. hyperpronation techniques If the initial attempt failed, a second attempt was performed. If the second attempt failed, the alternate technique was performed. Hyperpronation was 94% successful on the 1 st attempt. Supination-flexion was 69% successful on the 1 st attempt. Three patients failed two attempts at supination-flexion, and were then successfully reduced via hyperpronation.
32 Case 4 (4 y.o. male, elbow injury) Comparison of success and pain levels of supinationflexion and hyperpronation maneuvers in childhood nursemaid s elbow cases. Gunaydin, et. al., Am J Emerg Med Jul;31(7): Hyperpronation: 96% successful (65/68 patients) on the 1 st attempt Supination-flexion: 68% successful (56/82 patients) on the 1 st attempt Case 4 (4 y.o. male, elbow injury) Case 4 (4 y.o. male, elbow injury)
33 Case 4 (4 y.o. male, elbow injury) Case 5 (52 y.o. male, hip injury s/p MVC) Case 5 (52 y.o. male, hip injury s/p MVC)
34 Case 5 (52 y.o. male, hip injury s/p MVC) Case 5 (52 y.o. male, hip injury s/p MVC) Case 5 (52 y.o. male, hip injury s/p MVC)
35 Case 5 (52 y.o. male, hip injury s/p MVC) The Captain Morgan Technique The Captain Morgan Technique
36 Case 6 (68 y.o. male, rescued from a house fire) Case 6 (68 y.o. male, removed from a house fire)
37 Case 6 (68 y.o. male, removed from a house fire) Time Is Brain!! Emergency Cricothyroidotomy
38 Emergency Cricothyroidotomy Emergency Cricothyroidotomy
39 Summary Knee dislocation = vascular injury (until proven otherwise) Traumatic knee injury Severe pain Vascular injury!!! Diminished distal pulses or sensory deficits Vascular repair delayed more than 8 hours after injury carries an amputation rate of greater than 80%. FAST Exam
40 Pulmonary Ultrasound CT is only 64% sensitive for bowel injury. C R I T O E Ossification Centers of the Elbow
41 Supracondylar Fractures Hyperpronation Technique for Nursemaid s Elbow Captain Morgan Technique for Hip Dislocation
42 Emergency Cricothyroidotomy Thanks. See you next time.
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