A 20-something year old unknown male is brought to your community ED in a wheelchair by friends. They were at a party and a fight broke out. It was loud and dark and then they saw the patient collapse. His low back is covered in blood. He is awake but moaning.
A 25 y/o M pitching in a Sunday baseball game is hit in the face by a line drive. He is brought to the ED by his friends complaining of decreased visual acuity to his right eye accompanied by significant right peri-orbital swelling. At triage his VA is OD 20/100 OS 20/25 but at the time of assessment VA OD is limited to detection of light and his pupil is fixed and dilated, extra-ocular movements are intact. The team should recognize the need for lateral canthotomy based on the history and physical exam findings (including IOP) and mobilize the appropriate resources for bed-side lateral canthotomy as well as the need for emergent ophthalmology consult.
A 2.5 year old child falls from the 3rd floor balcony and presents to a community hospital. The team is expected to coordinate a thorough trauma survey. The patient will initially demonstrate compensated shock requiring aggressive resuscitation. After this initial phase, findings of severe head injury will become apparent. The team must optimize the patient for transfer to definitive care.
A 70-year old female is brought to the ED after lighting herself on fire while trying to light a cigarette. She will have a 15% TBSA burn (upper anterior chest and neck only) with inhalational injury. Preparation for intubation should be an early priority. Her prognosis is poor but survivable and it will be key to discuss goals of care with the family before proceeding with intubation and further burn care. A difficult intubation should be anticipated but is not encountered in this case.
The team receives advance notification from EMS about a 30 year-old female who is visibly pregnant and was in a car accident. Upon arrival to the ED the patient loses pulses and CPR begins. The team must begin ACLS/ATLS and proceed to resuscitative hysterotomy. After delivery they should begin neonatal resuscitation and continue management of the mother. Early consultation should be made to trauma surgery, NICU, and OB.
This is the sixth and final case in a six-part mini-series focusing on the management of geriatric patients in the ED. This series of cases was written by Drs. Rebecca Shaw, Nemat Alsaba, and Victoria Brazil. Dr. Rebecca Shaw is an emergency physician currently working as a medical education fellow within the Emergency Department of … Continue reading Geriatric Case 6: Elder Abuse
An 81-year old man falls down the stairs at home. He is initially asymptomatic but his level of consciousness declines and he starts to show signs of raised ICP. Providers must recognize and treat this, as well as reverse his anticoagulation, provide neuroprotective RSI and safely transport to the CT scanner. Providers must then talk with the patient’s wife, to provide information on his condition and prognosis and discuss the patient’s goals of care.
A 64-year old man is involved in a high-speed car crash. The trauma team is activated and he is brought directly to the ED. On arrival, he is hypoxic, tachycardic and altered. CXR reveals multiple rib fractures with a right-sided hemopneumothorax.
The team has been called to help in the ED after a 1 month-old male is brought in seizing. The team is expected to manage the seizure, but then will subsequently realize on examination there are concerning signs for non-accidental trauma, specifically head injury. The team will be expected to establish definitive airway management and consult with PICU and local child protection services.
A 44 year-old male arrives by EMS to a tertiary care ED where the trauma team has been activated. He was the driver in a single-vehicle MVC. He presents screaming and moaning with a GCS of 13. He has an obvious open fracture of his right forearm. He also has decreased air entry to the right side of his chest. The team will need to recognize the tension pneumothorax as part of their primary survey. They will then need to irrigate and splint the right arm after they have completed their secondary survey. As the secondary survey is being completed, the patient will become hypotensive again. This time, the team will find free fluid in the RUQ.