Blunt Trauma
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A Young Adult with Post-Traumatic Breathlessness, Unconsciousness and Rash
Shihan Mahmud Redwanul Huq 1, Ahmad Mursel Anam1, Nayeema Joarder1, Mohammed Momrezul Islam1, Raihan Rabbani2, Abdul Kader Shaikh3,4 [email protected] Case report A young adult with post-traumatic breathlessness, unconsciousness and rash Cite as: Huq SMR, A 23-year-old Bangladeshi male was referred to our with back slab at the previous healthcare facility. Anam AM, Joarder N, et al. hospital for gradual worsening of breathlessness During presentation at the emergency department, A young adult with post- over 3 h, developed following a road-accident he was conscious and oriented (Glasgow coma scale traumatic breathlessness, about 14 h previously. He had a close fracture of 15/15), tachycardic (heart rate 132 per min), blood unconsciousness and rash. mid-shaft of his right tibia, which was immobilised pressure 100/70 mmHg, tachypnoeic (respiratory Breathe 2019; 15: e126–e130. rate 34 per min) with oxygen saturation 89% on room air, and afebrile. Chest examination revealed a) b) restricted chest movement, hyper-resonant percussion notes and reduced breath sound on the left, and diffuse crackles on both sides. He was fit before the accident with no known medical illness. Oxygen supplementation (up to 8 L·min−1) and intravenous fluids were provided as required. Simultaneously, a portable anteroposterior radiograph of chest was performed (figure 1). Task 1 Analyse the chest radiograph. Figure 1 Chest radiography: a) anteroposterior view; b) magnified view of same image showing the clear margin of a pneumothorax on the left-hand side (dots and arrow). @ERSpublications Can you diagnose this young adult with post-traumatic breathlessness, unconsciousness and rash? http://bit.ly/2LlpkiV e126 Breathe | September 2019 | Volume 15 | No 3 https://doi.org/10.1183/20734735.0212-2019 A young adult with post-traumatic breathlessness Answer 1 a) b) The bilateral patchy opacities are likely due to pulmonary contusion or acute respiratory distress syndrome (ARDS) along with the left- sided traumatic pneumothorax. -
Diagnoses to Include in the Problem List Whenever Applicable
Diagnoses to include in the problem list whenever applicable Tips: 1. Always say acute or open when applicable 2. Always relate to the original trauma 3. Always include acid-base abnormalities, AKI due to ATN, sodium/osmolality abnormalities 4. Address in the plan of your note 5. Do NOT say possible, potential, likely… Coders can only use a real diagnosis. Make a real diagnosis. Neurological/Psych: Head: 1. Skull fracture of vault – open vs closed 2. Basilar skull fracture 3. Facial fractures 4. Nerve injury____________ 5. LOC – include duration (max duration needed is >24 hrs) and whether they returned to neurological baseline 6. Concussion with or without return to baseline consciousness 7. DAI/severe concussion with or without return to baseline consciousness 8. Type of traumatic brain injury (hemorrhages and contusions) – include size a. Tiny = <0.6 cm b. Small/moderate = 0.6-1 cm c. Large/extensive = >1 cm 9. Cerebral contusion/hemorrhage 10. Cerebral edema 11. Brainstem compression 12. Anoxic brain injury 13. Seizures 14. Brain death Spine: 1. Cervical spine fracture with (complete or incomplete) or without cord injury 2. Thoracic spine fracture with (complete or incomplete) or without cord injury 3. Lumbar spine fracture with (complete or incomplete) or without cord injury 4. Cord syndromes: central, anterior, or Brown-Sequard 5. Paraplegia or quadriplegia (any deficit in the upper extremity is consistent with quadriplegia) Cardiovascular: 1. Acute systolic heart failure 40 2. Acute diastolic heart failure 3. Chronic systolic heart failure 4. Chronic diastolic heart failure 5. Combined heart failure 6. Cardiac injury or vascular injuries 7. -
Section 9 Patient Care Record Documentation Guidelines
SECTION 9 PATIENT CARE RECORD DOCUMENTATION GUIDELINES Quick Reference Introduction to Patient Care Record Documentation 9-2 When to complete a Patient Care Record 9-3 Why use a patient Record 9-3 How to complete a Patient Record 9-3 Approaches to Documentation: System by System 9-4 Body Region 9-5 Gathering information using CHART format (System by System) 9-5 Gathering information using CHART format (Body Region) 9-6 Narrative using CHART format 9-7 Gathering information using SOAP format (System by System) 9-8 9-8 Gathering information using SOAP format (Body Region) 9-9 Narrative using SOAP format Illness and Injury Reference for Competency Sign offs 4.3 and 6.1 9-10 Introduction Patient Care Record Documentation Medavie HealthEd recognizes the need for students to provide detailed and accurate Patient Care Record Documentation. It is important for the student, school staff and preceptors to recognize the value of documenting patient care, in that it serves as a safety mechanism for the patient, as well as the practitioner. To that end, students, school staff and preceptors must develop the student‟s ability to document all aspects of the patient care they provide. Documentation provides a written record between practitioners of the assessment and treatment they have provided. This establishes greater patient safety and the smooth transition of patient care from one provider to another. In regard to the student and practitioner, accurate and detailed information on the Patient Care Record will serve as the primary record in any litigation that may be brought forward by a patient or their family. -
Managing a Rib Fracture: a Patient Guide
Managing a Rib Fracture A Patient Guide What is a rib fracture? How is a fractured rib diagnosed? A rib fracture is a break of any of the bones that form the Your doctor will ask questions about your injury and do a rib cage. There may be a single fracture of one or more ribs, physical exam. or a rib may be broken into several pieces. Rib fractures are The doctor may: usually quite painful as the ribs have to move to allow for normal breathing. • Push on your chest to find out where you are hurt. • Watch you breathe and listen to your lungs to make What is a flail chest? sure air is moving in and out normally. When three or more neighboring ribs are fractured in • Listen to your heart. two or more places, a “flail chest” results. This creates an • Check your head, neck, spine, and belly to make sure unstable section of chest wall that moves in the opposite there are no other injuries. direction to the rest of rib cage when you take a breath. • You may need to have an X-ray or other imaging test; For example, when you breathe in your rib cage rises out however, rib fractures do not always show up on X-rays. but the flail chest portion of the rib cage will actually fall in. So you may be treated as though you have a fractured This limits your ability to take effective deep breaths. rib even if an X-ray doesn’t show any broken bones. -
Cervical Spine Injury Risk Factors in Children with Blunt Trauma Julie C
Cervical Spine Injury Risk Factors in Children With Blunt Trauma Julie C. Leonard, MD, MPH,a Lorin R. Browne, DO,b Fahd A. Ahmad, MD, MSCI,c Hamilton Schwartz, MD, MEd,d Michael Wallendorf, PhD,e Jeffrey R. Leonard, MD,f E. Brooke Lerner, PhD,b Nathan Kuppermann, MD, MPHg BACKGROUND: Adult prediction rules for cervical spine injury (CSI) exist; however, pediatric rules abstract do not. Our objectives were to determine test accuracies of retrospectively identified CSI risk factors in a prospective pediatric cohort and compare them to a de novo risk model. METHODS: We conducted a 4-center, prospective observational study of children 0 to 17 years old who experienced blunt trauma and underwent emergency medical services scene response, trauma evaluation, and/or cervical imaging. Emergency department providers recorded CSI risk factors. CSIs were classified by reviewing imaging, consultations, and/or telephone follow-up. We calculated bivariable relative risks, multivariable odds ratios, and test characteristics for the retrospective risk model and a de novo model. RESULTS: Of 4091 enrolled children, 74 (1.8%) had CSIs. Fourteen factors had bivariable associations with CSIs: diving, axial load, clotheslining, loss of consciousness, neck pain, inability to move neck, altered mental status, signs of basilar skull fracture, torso injury, thoracic injury, intubation, respiratory distress, decreased oxygen saturation, and neurologic deficits. The retrospective model (high-risk motor vehicle crash, diving, predisposing condition, neck pain, decreased neck mobility (report or exam), altered mental status, neurologic deficits, or torso injury) was 90.5% (95% confidence interval: 83.9%–97.2%) sensitive and 45.6% (44.0%–47.1%) specific for CSIs. -
Early Management of Retained Hemothorax in Blunt Head and Chest Trauma
World J Surg https://doi.org/10.1007/s00268-017-4420-x ORIGINAL SCIENTIFIC REPORT Early Management of Retained Hemothorax in Blunt Head and Chest Trauma 1,2 1,8 1,7 1 Fong-Dee Huang • Wen-Bin Yeh • Sheng-Shih Chen • Yuan-Yuarn Liu • 1 1,3,6 4,5 I-Yin Lu • Yi-Pin Chou • Tzu-Chin Wu Ó The Author(s) 2018. This article is an open access publication Abstract Background Major blunt chest injury usually leads to the development of retained hemothorax and pneumothorax, and needs further intervention. However, since blunt chest injury may be combined with blunt head injury that typically requires patient observation for 3–4 days, other critical surgical interventions may be delayed. The purpose of this study is to analyze the outcomes of head injury patients who received early, versus delayed thoracic surgeries. Materials and methods From May 2005 to February 2012, 61 patients with major blunt injuries to the chest and head were prospectively enrolled. These patients had an intracranial hemorrhage without indications of craniotomy. All the patients received video-assisted thoracoscopic surgery (VATS) due to retained hemothorax or pneumothorax. Patients were divided into two groups according to the time from trauma to operation, this being within 4 days for Group 1 and more than 4 days for Group 2. The clinical outcomes included hospital length of stay (LOS), intensive care unit (ICU) LOS, infection rates, and the time period of ventilator use and chest tube intubation. Result All demographics, including age, gender, and trauma severity between the two groups showed no statistical differences. -
Anesthesia for Trauma
Anesthesia for Trauma Maribeth Massie, CRNA, MS Staff Nurse Anesthetist, The Johns Hopkins Hospital Assistant Professor/Assistant Program Director Columbia University School of Nursing Program in Nurse Anesthesia OVERVIEW • “It’s not the speed which kills, it’s the sudden stop” Epidemiology of Trauma • ~8% worldwide death rate • Leading cause of death in Americans from 1- 45 years of age • MVC’s leading cause of death • Blunt > penetrating • Often drug abusers, acutely intoxicated, HIV and Hepatitis carriers Epidemiology of Trauma • “Golden Hour” – First hour after injury – 50% of patients die within the first seconds to minutesÆ extent of injuries – 30% of patients die in next few hoursÆ major hemorrhage – Rest may die in weeks Æ sepsis, MOSF Pre-hospital Care • ABC’S – Initial assessment and BLS in trauma – GO TEAM: role of CRNA’s at Maryland Shock Trauma Center • Resuscitation • Reduction of fractures • Extrication of trapped victims • Amputation • Uncooperative patients Initial Management Plan • Airway maintenance with cervical spine protection • Breathing: ventilation and oxygenation • Circulation with hemorrhage control • Disability • Exposure Initial Assessment • Primary Survey: – AIRWAY • ALWAYS ASSUME A CERVICAL SPINE INJURY EXISTS UNTIL PROVEN OTHERWISE • Provide MANUAL IN-LINE NECK STABILIZATION • Jaw-thrust maneuver Initial Assessment • Airway cont’d: – Cervical spine evaluation • Cross table lateral and swimmer’s view Xray • Need to see all seven cervical vertebrae • Only negative CT scan R/O injury Initial Assessment • Cervical -
Surgical Case Conference
Surgical Case Conference HENRY R. GOVEKAR, M.D. PGY-2 UNIVERSITY OF COLORADO HOSPITAL Objectives Introduce Patient Hospital Course Management of Injuries Decisions to make Outcome History and Physical 50y/o M who was transferred to Denver Health on post injury day #3. Patient involved in motorcycle collision in Vail; admit to local hospital. Patient riding with female companion, tight turn, laid down the bike on road, companion landing on top of patient. Companion suffered minor injuries including abrasions and knee pain History and Physical Our patient – c/o Right shoulder pain, left flank pain PMH: GERD; peptic ulcer PSH: hx of surgery for intractable ulcerative disease – distal gastrectomy with Billroth I, ? Of revision to Roux-en-Y gastrojejunostomy Meds: prilosec Social: denies tobacco; quit ETOH 13 years ago after MVC; denies IVDA NKDA History and Physical Exam per OSH: a&ox3, minor distress HR 110’s, BP 130/70’s, on NRB mask with sats 98% Multiple abrasions on scalp, arms , knees c/o right arm pain, left sided flank pain No other obvious injuries After fluid resuscitation – HD stable Sent to CT for abd/pelvis Post 10th rib fx Grade 3 splenic laceration Spleen Injury Scale Grade I Injury Grade IV injury http://emedicine.medscape.com/article/373694-media Grade V injury http://emedicine.medscape.com/article/373694-media What should our plan be? Management of Splenic Injuries Stable vs. Unstable Unstable – OR Stable – abd CT scan CT scan Other significant injury – OR Documented splenic injury Grade I, -
Fat Embolism Syndrome
Crit Care & Shock (2008) 11 : 83-93 Fat Embolism Syndrome Gavin M. Joynt, Thomas ST Li, Joey KM Wai, Florence HY Yap Abstract The classical syndrome of fat embolism is recognition as well as the development of preventive characterized by the triad of respiratory failure, and therapeutic strategies. Early fracture fi xation neurologic dysfunction and the presence of a is likely to reduce the incidence of fat embolism petechial rash. Fat embolism syndrome (FES) syndrome and pulmonary complications; however occurs most commonly following orthopedic the best fi xation technique remains controversial. trauma, particularly fractures of the pelvis or long The use of prophylactic corticosteroids may be bones, however non-traumatic fat embolism has considered to reduce the incidence of FES and in also been known to occur on rare occasions. Because selected high-risk trauma patients but effects on no defi nitive consensus on diagnostic criteria exist, outcome are not proved. New reaming and venting the accurate assessment of incidence, comparative techniques have potential to reduce the incidence research and outcome assessment is diffi cult. A of FES during arthroplasty. Unfortunately, no reasonable estimate of incidence in patients after specifi c therapies have been proven to be of benefi t long bone or pelvic fractures appears to be about in FES and treatment remains supportive with 3-5%. The FES therefore remains an important priority being given to the maintenance of adequate cause of morbidity and mortality and warrants oxygenation. further investigation and research to allow proper Key words: respiratory failure, petechiae, rash, trauma, orthopedic, fracture Introduction The classical syndrome of fat embolism is characterized following orthopedic trauma, particularly fractures of by the triad of respiratory failure, neurologic the pelvis or long bones, however non-traumatic fat dysfunction and the presence of a petechial rash [1,2]. -
Crush Injuries Pathophysiology and Current Treatment Michael Sahjian, RN, BSN, CFRN, CCRN, NREMT-P; Michael Frakes, APRN, CCNS, CCRN, CFRN, NREMT-P
LWW/AENJ LWWJ331-02 April 23, 2007 13:50 Char Count= 0 Advanced Emergency Nursing Journal Vol. 29, No. 2, pp. 145–150 Copyright c 2007 Wolters Kluwer Health | Lippincott Williams & Wilkins Crush Injuries Pathophysiology and Current Treatment Michael Sahjian, RN, BSN, CFRN, CCRN, NREMT-P; Michael Frakes, APRN, CCNS, CCRN, CFRN, NREMT-P Abstract Crush syndrome, or traumatic rhabdomyolysis, is an uncommon traumatic injury that can lead to mismanagement or delayed treatment. Although rhabdomyolysis can result from many causes, this article reviews the risk factors, symptoms, and best practice treatments to optimize patient outcomes, as they relate to crush injuries. Key words: crush syndrome, traumatic rhabdomyolysis RUSH SYNDROME, also known as ology, pathophysiology, diagnosis, and early traumatic rhabdomyolysis, was first re- management of crush syndrome. Cported in 1910 by German authors who described symptoms including muscle EPIDEMIOLOGY pain, weakness, and brown-colored urine in soldiers rescued after being buried in struc- Crush injuries may result in permanent dis- tural debris (Gonzalez, 2005). Crush syn- ability or death; therefore, early recognition drome was not well defined until the 1940s and aggressive treatment are necessary to when nephrologists Bywaters and Beal pro- improve outcomes. There are many known vided descriptions of victims trapped by mechanisms inducing rhabdomyolysis includ- their extremities during the London Blitz ing crush injuries, electrocution, burns, com- who presented with shock, swollen extrem- partment syndrome, and any other pathology ities, tea-colored urine, and subsequent re- that results in muscle damage. Victims of nat- nal failure (Better & Stein, 1990; Fernan- ural disasters, including earthquakes, are re- dez, Hung, Bruno, Galea, & Chiang, 2005; ported as having up to a 20% incidence of Gonzalez, 2005; Malinoski, Slater, & Mullins, crush injuries, as do 40% of those surviving to 2004). -
T5 Spinal Cord Injuries
Spinal Cord (2020) 58:1249–1254 https://doi.org/10.1038/s41393-020-0506-7 ARTICLE Predictors of respiratory complications in patients with C5–T5 spinal cord injuries 1 2,3 3,4 1,5 1,5 Júlia Sampol ● Miguel Ángel González-Viejo ● Alba Gómez ● Sergi Martí ● Mercedes Pallero ● 1,4,5 3,4 1,4,5 1,4,5 Esther Rodríguez ● Patricia Launois ● Gabriel Sampol ● Jaume Ferrer Received: 19 December 2019 / Revised: 12 June 2020 / Accepted: 12 June 2020 / Published online: 24 June 2020 © The Author(s), under exclusive licence to International Spinal Cord Society 2020 Abstract Study design Retrospective chart audit. Objectives Describing the respiratory complications and their predictive factors in patients with acute traumatic spinal cord injuries at C5–T5 level during the initial hospitalization. Setting Hospital Vall d’Hebron, Barcelona. Methods Data from patients admitted in a reference unit with acute traumatic injuries involving levels C5–T5. Respiratory complications were defined as: acute respiratory failure, respiratory infection, atelectasis, non-hemothorax pleural effusion, 1234567890();,: 1234567890();,: pulmonary embolism or haemoptysis. Candidate predictors of these complications were demographic data, comorbidity, smoking, history of respiratory disease, the spinal cord injury characteristics (level and ASIA Impairment Scale) and thoracic trauma. A logistic regression model was created to determine associations between potential predictors and respiratory complications. Results We studied 174 patients with an age of 47.9 (19.7) years, mostly men (87%), with low comorbidity. Coexistent thoracic trauma was found in 24 (19%) patients with cervical and 35 (75%) with thoracic injuries (p < 0.001). Respiratory complications were frequent (53%) and were associated to longer hospital stay: 83.1 (61.3) and 45.3 (28.1) days in patients with and without respiratory complications (p < 0.001). -
Delayed Traumatic Hemothorax in Older Adults
Open access Brief report Trauma Surg Acute Care Open: first published as 10.1136/tsaco-2020-000626 on 8 March 2021. Downloaded from Complication to consider: delayed traumatic hemothorax in older adults Jeff Choi ,1 Ananya Anand ,1 Katherine D Sborov,2 William Walton,3 Lawrence Chow,4 Oscar Guillamondegui,5 Bradley M Dennis,5 David Spain,1 Kristan Staudenmayer1 ► Additional material is ABSTRACT very small hemothoraces rarely require interven- published online only. To view, Background Emerging evidence suggests older adults tion whereas larger hemothoraces often undergo please visit the journal online immediate drainage. However, emerging evidence (http:// dx. doi. org/ 10. 1136/ may experience subtle hemothoraces that progress tsaco- 2020- 000626). over several days. Delayed progression and delayed suggests HTX in older adults with rib fractures may development of traumatic hemothorax (dHTX) have not experience subtle hemothoraces that progress in a 1Surgery, Stanford University, been well characterized. We hypothesized dHTX would delayed fashion over several days.1 2 If true, older Stanford, California, USA be infrequent but associated with factors that may aid adults may be at risk of developing empyema or 2Vanderbilt University School of Medicine, Nashville, Tennessee, prediction. other complications without close monitoring. USA Methods We retrospectively reviewed adults aged ≥50 Delayed progression and delayed development of 3Radiology, Vanderbilt University years diagnosed with dHTX after rib fractures at two traumatic hemothorax (dHTX) have not been well Medical Center, Nashville, level 1 trauma centers (March 2018 to September 2019). characterized in literature. The ageing US popula- Tennessee, USA tion and increasing incidence of rib fractures among 4Radiology, Stanford University, dHTX was defined as HTX discovered ≥48 hours after Stanford, California, USA admission chest CT showed either no or ’minimal/trace’ older adults underscore a pressing need for better 5Department of Surgery, HTX.