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.
The case will start with an EMS patch indicating that they are 2 minutes out with multi-trauma from a 2 car MVC. Two patients will then arrive within 1 minute of each other. The first will have gone VSA en route from presumed blunt trauma. This patient will not regain a pulse. The second patient will arrive with significant burns from a car fire, and will have GCS of 3 necessitating intubation. All attempts at intubation will be unsuccessful, and a surgical airway must be performed. The team will need to prioritize resources between the two patients and realize that an ED thoracotomy is not reasonable in the first patient.
A 16-year-old female presents following an MVC. Past medical history is significant for hemophilia A. She has a laceration on her arm and a bruise on her forehead, but denies HA/N/V. The learner should recognize high potential for bleeding, and implement immediate treatment with rVIII replacement, along with pan-CT imaging. The CT head will show a small ICH. The patient wants to leave AMA following normal CT results, and the learner must preform a capacity assessment and outline a plan of action for the incompetent patient. The patient should be sedated and/or intubated anticipating decline using neuroprotective measures. Consults should be made to the ICU and hematology.
A 32-year-old female presents after being bucked off of her horse. She is brought in as a trauma team activation because of a low BP. Her primary survey will reveal a boggy hematoma over her right temporal area as well as an unstable pelvis. Her initial GCS will be 8. The team will proceed through airway management in a hypotensive, head-injured trauma patient while also binding her pelvis. The patient eventually shows signs of brain herniation, which the team will need to manage prior to consultant arrival.
The case will begin with the arrival of patient from a house fire who has 30%TBSA burns. The team will be expected to recognize the need for intubation and fluid resuscitation. After successful intubation, a second patient will arrive from an altercation outside a bar. He appears to have a blunt traumatic head injury after being repeatedly kicked. The team is expected to recognize hypoglycemia in the context of a minor head injury and provide immediate glucose replacement. During the management of the head injured patient, the burn patient will continue to by hypotensive. The team will need to recognize the possibility of CN toxicity. The patient will also become more difficult to ventilate and will require an escharotomy.
A 33 year old G2P1 female at 32 weeks GA presents with blunt trauma following an MVC. She will be hypotensive due to both hypovolemic shock from a pelvic fracture and obstructive shock from a tension pneumothorax. Fetal monitoring will show the fetus in distress with tachycardia and late decelerations. Early airway intervention should be employed, with thoughtful selection of drugs for sedation and paralysis given the pregnancy. After intubation, the patient will remain hypotensive. She will require massive transfusion and coordination of care between orthopedics, general surgery, and obstetrics. The patient’s husband will also arrive after intubation and the team must give him the bad news.
30 year-old female is brought into the ED at 4 AM by a man who found her lying at the side of the road with no coat or shoes. It is minus 30 degrees Celsius outside. On arrival she has a reduced LOC, laboured breathing, a right-sided pneumothorax, cyanotic extremities, a left radius & ulna fracture, and a right tib-fib fracture. The team is required to use both active and passive rewarming strategies. Regardless of the team’s efforts, the patient in this case will arrest. Upon ROSC, they are required to continue rewarming as well as to address the other traumatic injuries.
A young male and a middle-aged female are brought to the ED after a T-bone MVC at an unknown speed. Both patients were drivers. The emergency team is expected to triage the patients accordingly and to split the team so that both patients are treated.
A 21 year old male is brought to your tertiary care ED by EMS after being stabbed by a friend. EMS initiated spinal precautions and failed several attempts to intubate en route. On arrival, the patient is being bagged and has a single stab wound to the right posterolateral neck. He requires emergent intubation for airway protection. After intubation, his blood pressure drops but his heart rate remains in the 70s. His blood pressure will stabilize only after appropriate fluid resuscitation and vasopressor initiation.