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A Case of Head vs. Bat EM Sub-I Presentation Kathy Staats, MS IV.

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Presentation on theme: "A Case of Head vs. Bat EM Sub-I Presentation Kathy Staats, MS IV."— Presentation transcript:

1 A Case of Head vs. Bat EM Sub-I Presentation Kathy Staats, MS IV

2  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.

3  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

4  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

5  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

6  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

7 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%

8  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%

9  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%

10  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%

11  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.

12  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

13  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.

14  " 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 — 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.


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