Geriatric Case 5: Trauma with Head Injury

This case is the fifth 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 the Gold Coast Hospital and Health Service in Queensland, Australia. Dr. Nemat Alsaba (@talk2nemat) is an emergency physician with a special interest in geriatric emergency medicine, medical education and simulation. She is trying her best to combine these interests to improve geriatric patient care across all health sectors. She is also an assistant professor in medical education and simulation at Bond university. Dr. Victoria Brazil is an emergency physician and medical educator. She is Professor of Emergency Medicine and Director of Simulation at the Gold Coast Health Service, and at Bond University medical program. Victoria’s main interests are in connecting education with patient care – through healthcare simulation, technology enabled learning, faculty development activities, and talking at conferences. Victoria is an enthusiast in the social media and #FOAMed world (@SocraticEM), and she is co-producer of Simulcast (Simulationpodcast.com).

Why It Matters

Elderly patients who have sustained trauma are frequently encountered in the ED. These patients have unique physiology and are often complex due to frailty and polypharmacy concerns. Care of the elderly trauma patient requires attention to these complexities, to goals of care, and to communication with family members. This case gives the opportunity to learn and enhance these skills.

Clinical Vignette

The bedside nurse informs you that “EMS just off-loaded an elderly male to the resuscitation bay. He had a fall down the stairs and sustained a head injury. He was GCS 15 and hemodynamically stable when they picked him up, so they didn’t activate the trauma team, but he has deteriorated during transport. He has an obvious large, boggy scalp hematoma over the left parietal region. I am worried because he’s getting restless and won’t follow commands.”

Case Summary

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.

Download the case here:

Geriatric Trauma with Head Injury

ECG for the case found here:

Geriatric Trauma ECG

ECG Source: https://en.ecgpedia.org/index.php?title=Atrial_Fibrillation

CXR for the case found here:

Geriatric Trauma CXR

Image courtesy of Dr Jeremy Jones, Radiopaedia.org, rID: 6410

Pelvic XR for the case found here:

Geriatric Trauma Pelvic XR

Image courtesy of Dr Jeremy Jones, Radiopaedia.org, rID: 28928

Multi-trauma (Kicked off a Horse)

This case is written by Dr. Kyla Caners. She is a staff emergency physician in Hamilton, Ontario and the Simulation Director of McMaster University’s FRCP-EM program. She is also one of the Editors-in-Chief here at EmSimCases.

Why it Matters

Management of trauma patients with multiple intercurrent injuries can be challenging. This case provides an opportunity for junior learners to stretch themselves beyond their comfort zones. In particular, this case highlights the following:

  • The need for a systematic approach to the initial assessment and ongoing re-assessment of any complex trauma patient
  • The importance of prioritizing tasks and adjusting priorities as patient status changes
  • The complexity of managing a hypotensive, head-injured patient

Clinical Vignette

A 32-year-old female presents as a trauma activation with EMS after being bucked off of her horse. Her mom witnessed the episode and called EMS because she seemed groggy. She has had a low BP with EMS on route. Her current BP is 80/40.

Case Summary

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.

Download the case here: Pelvic Fracture and SDH

ECG for the case found here:

Sinus tachycardia

(ECG source: https://i0.wp.com/lifeinthefastlane.com/wp-content/uploads/2011/12/sinus-tachycardia.jpg)

Pre-intubation CXR for the case found here:

normal female CXR radiopedia

(CXR source: https://radiopaedia.org/cases/normal-chest-radiograph-female-1)

PXR for the case found here:

Pelvic fracture

(PXR source: https://littlemedic.files.wordpress.com/2013/01/pelvis_0_1.jpg)

Post-intubation CXR for the case found here:

normal-intubation2

(CXR source: https://emcow.files.wordpress.com/2012/11/normal-intubation2.jpg)

Ultrasound showing free fluid in RUQ found here:

RUQ FF

Ultrasound showing normal lung sliding found here:

Ultrasound showing no pericardial effusion found here:

(All U/S images are courtesy of McMaster PoCUS Subspecialty Training Program)

Multi-trauma case: burn and head injury

This case is written by Dr. Donika Orlich. She is a PGY5 Emergency Medicine resident at McMaster University who also completed a fellowship in Simulation and Medical Education last year.

Why it Matters

Too often in the Emergency Department, we are faced with the challenge of simultaneously managing two patients who each require immediate care. This case does an excellent job of highlighting the following issues that often arise as a result:

  • The importance of delegating any tasks that may be delegated
  • The need to clarify who is taking ownership of a patient’s management when there is help available from others (such as another ED MD or a trauma team leader)
  • How essential it is to call for help early

In addition, this case also features some key medical content, including:

  • The recognition and treatment of cyanide toxicity in the context of a house fire
  • The preparation and management of a potentially difficult airway
  • The need to perform an escharotomy in a patient with circumferential chest burns and high ventilation pressures
  • The importance of checking a blood glucose on all patients with an altered level of consciousness

Clinical Vignette

Patient A: “You are working in a tertiary care ED. A 33 year old male has just been brought in by EMS after being dragged out of a house fire. He has been unresponsive with EMS and has significant burns to his chest, arm, and leg. The etiology of the fire is unclear, but the home was severely damaged.”

Midway through the case, Patient B will arrive.

Patient B (To be stated by EMS in handover): “We have a 55 year old male here who was repeatedly kicked during an altercation outside a bar. His GCS was 15 on arrival, but it just decreased to 13 in the ambulance bay, and he has become combative. We put him in C-spine collar at the scene. He has lots of bruising to face and head, but no other obvious injuries. When he was more cooperative, the patient denied other medical history or allergies initially.”

Case Summary

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 Note on Technical Requirements

At McMaster, we recently ran this case for our senior residents. It was a huge success! It did, however, require many resources. We used one high fidelity mannequin and one standardized patient actor. We also had two confederate nurses (one per patient). We had three staff physicians as instructors. One instructor was assigned to observing each patient’s management. The third instructor briefly played the paramedic and also coordinated between the two instructors and the sim tech to ensure the case ran smoothly. We ran the case with five residents participating. We had them pre-assigned to roles of trauma team leader, senior emerg resident, senior anesthesia resident, senior general surgery resident, and senior orthopedic resident. (This is often the make-up of our trauma team.)

Download the case here: Multi-trauma Case: Burn and Head Injury

CXR for Patient B found here:

normal-cxr-patient-b

(CXR source: http://www.pharmacology2000.com/respiratory_anesthesiology/pulmonary_assessment/pulmonary_assessment2.htm)

PXR for Patient B found here:

normal-pelvis-male

(PXR source: http://radiopaedia.org/articles/pelvis-1)

Two Patient Trauma

This case was written by Dr. Martin Kuuskne from McGill University. Dr. Kuuskne is a PGY5 Emergency Medicine resident and one of the editors-in-chief at EMSimCases.

Why it Matters

Emergency Medicine often requires care providers to be in multiple places at once. It is not uncommon to have two patients simultaneously require urgent or semi-urgent intervention. This case helps learners to develop this important skill by highlighting:

  • The challenges of triaging patients as immediately urgent or less urgent
  • The need to assign tasks to team members
  • The importance of adhering to the basics, even in a taxing situation

Clinical Vignette

Before entering the room: You are working the day shift in a tertiary care emergency department with full surgical capabilities. EMS is en-route to the hospital with two patients, a 37-year-old male and a 65 year old female, who were both drivers of a t-bone MVC of unknown speed. The ambulances will arrive in 2 minutes.

Upon entering the room: Each patient will be accompanied with a paramedic who will give this information and will be available to stay if asked.

Patient A: “37 year old male, belted driver, he got t-boned on the driver’s side. There was significant intrusion of his side door. We’re not sure if there was a loss of consciousness, we put him on a non-rebreather and his SAT was around 92%, tachy at 105 with an OK BP around 110 systolic during the ride.”

Patient B: “65 year old female, belted driver who t-boned the other car. The front of her car was totaled. Airbags were deployed and there was a brief loss of consciousness. We put on the collar ASAP. Vitals were stable en route but she was a bit confused during the ride. No vomiting.”

Case Summary

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.

Patient A: The team is expected to recognize respiratory compromise secondary to pneumothorax. Needle decompression and tube thoracostomy should be administered. The patient will in remain in respiratory compromise post-decompression and the team should consider intubation. If the pneumothorax is not recognized or treated, the patient will arrest. On secondary survey, the patient will complain of pelvic pain in addition to a positive eFAST evaluation. The team should activate the massive transfusion protocol (MTP) and activate the trauma/surgery team.

Patient B: The team is expected to recognize hypoglycemia in the context of a minor head injury. Immediate glucose replacement is required.

Download the case here:  Two for one MVC

CXR for Patient A found here:

left flail chest

(CXR source: http://learningradiology.com/archives2009/COW%20353-Flail%20Chest/caseoftheweek353page.htm)

Pelvic xray for Patient A found here:

open book # from radiopedia

(Xray source: http://radiopaedia.org/articles/open-book-fracture)

Left lung U/S for Patient A found here:

Right lung U/S for Patient A found here:

RUQ FAST image for Patient A found here:

RUQ FF

Pericardial U/S for Patient A found here:

(All U/S images are courtesy of McMaster PoCUS Subspecialty Training Program.)

CXR for Patient B found here:

normal female CXR radiopedia

(CXR source: http://radiopaedia.org/articles/normal-position-of-diaphragms-on-chest-radiography)