Presentation on theme: "A Case of Head vs. Bat EM Sub-I Presentation Kathy Staats, MS IV."— Presentation transcript:
A Case of Head vs. Bat EM Sub-I Presentation Kathy Staats, MS IV
25 M brings self to ED one hour post blow to the head with aluminum baseball bat. Pt hit once on head Deflected another attempt w/left hand. Pt denies loss of consciousness or memory/ dizziness/ lightheadedness/ change in vision or hearing/ tinnitus/ nausea/ vomiting/ difficulty or change in breathing.
Pt reports HA 8/10 throughout head “Extreme pain” around laceration Pt reports minimal tearing of the eyes and a runny nose ROS otherwise unremarkable Pt reports most recent tetanus shot in 10/2011 PMH: Pt denies history of concussion, surgeries, or chronic conditions. NKDA. No current medications. SH: Social smoker and drinker
V/S: 144/89 76 bpm 16 rpm 99% RA 98.8 °F Gen: Well-nourished male, A&Ox 3 HEENT: 2- inch, non-bleeding linear laceration above left eyebrow with 0.5- inch lac perpendicular to the major injury. Laceration extends to intact galea. No battlesign/raccoon eyes. No fluid from ears, no gross crepitus or step-off of skull or vertebrae. EOMI, MMM, PERRL, ø JVD, ø LAD
Neuro: CN II-XII intact. Grossly normal gait. 5/5 strength in all limbs. Sensation present & similar in all limbs. Negative Romberg’s test. Extremities: Point tenderness on dorsal hand surface of left thumb. Decreased ROM in all directions. 3/5 Strength of thumb. CV/Pulm/GI: RRR nl S1S2, CTA B/L, +BS, -TTP
For Focused Trauma: ◦ Always ABCs ◦ Disability and Neuro ◦ Exposure For Scalp Lacerations: 1.History 2.PE 3.Imaging and Consults – a.Contrast or No? b.Who and Why? 4.Wound Debridement & Repair
NSAID (N with N) N euro Deficit S pinal Tenderness A ltered LOC I ntoxication D istracting Injury If NOT present, NO radiography Sn: 97-100% Sp: 13%
Age ≥ 65 Extremity Paresthesias Dangerous Mechanism 1 If present, do radiography If not, onto 2 Sitting in ED Ambulating ever Delayed neck pain Rear end MVC No c-spine tenderness 2 3 If present, onto 3 If not, onto x-ray Test active ROM < 45° L or R = x-ray Full ROM = cleared c-spine! Sn: 91% Sp: 37%
S eizure H eadache A ge > 60 V omiting E toh or Drug Intoxication ME mory: Persistent anterograde amnesia Above the Clavicle - Visible Trauma Sn: 100% Sp: 52%
F racture: Suspected open/depressed skull fracture F racture : Suspected basilar skull fracture G CS < 15 at 2 hours post-injury D angerous Mechanism A ge ≥ 65 M emory: Retrograde amnesia from event ≥ 30 min N/V omiting ≥ 2 episodes Sn: 100% Sp: 88%
Case discussed w/attending. Plan to CT head, and suture and release if benign read. Hours later, CT has not been read and radiology cannot be reached. Next shift attending reviews CT w/medical student and no abnormalities are noted. Pt is sutured and prepared for discharge.
Lidocaine w/epi on face (before irrigation): ◦ Max dose 7 mg/kg ≈ Given 4 ml locally ◦ 2 ml as nerve block in supraorbital notch How much water & what kind for irrigation? ◦ 60 ml/cm ≈ 240 ml of clean H2O (NaCl, tap, etc) Sutured inner & outer layers: ◦ 5 stitches with 4.0 Vicryl on inner layer, ◦ 16 stitches with 5.0 Nylon on skin ◦ Can be left open to air, cleaned with soap and water When to come back/why to come back o 5 days post forehead lac for removal & f/u
Original attending of case reviews CT “Mildly depressed fracture anterior wall left frontal sinus. Soft tissue defect of left frontal scalp.” ENT is consulted, but pt leaves AMA prior to exam. Nine days later pt returns to ED for suture removal. Laceration is healing well, with no swelling/ erythema or associated pain. - ROS, no HA/dizziness/ lightheadedness/rhinorrhea. Appointment is scheduled with ENT for following day. Pt does not attend.
" Assessment and Management of Scalp Lacerations." UpToDate. Web. 18 July 2012.. " The New England Journal of Medicine." Validity of a Set of Clinical Criteria to Rule Out Injury to the Cervical Spine in Patients with Blunt Trauma â NEJM. Web. 18 July 2012. Stiell, Ian G., et all. " The Canadian C - Spine Rule versus the NEXUS Low - Risk Criteria in Patients with Trauma." New England Journal of Medicine 349.26 (2003): 2510-518. Print.