This is a multi-case simulation. The initial patient will present with a STEMI. The resident will need to arrange for cardiac catheterization and provide appropriate medical treatment. The exact moment these orders are completed, a stroke activation will be called for a patient eligible for tPA. Stroke protocol needs to be followed and tPA will need to be given. As soon as tPA is pushed, the resident will be handed an EKG with signs of hyperkalemia and told that a patient with depression has checked in. The resident will need to immediately evaluate the patient with hyperkalemia and give appropriate medications or they will decline. As they are pushing the medications, a Trauma Level One will be called. The trauma will be an open book pelvic fracture with hypotension and a positive FAST. The patient will need a pelvic binder, blood products, and go immediately to the OR. At this time, the resident will need to follow up on the stroke and hyperkalemia patients before evaluating the patient presenting with depression.
Securing the airway of a severely traumatized patient is fraught with difficulties. There can be anatomic difficulties associated with facial and neck injuries. There are often physiologic difficulties from uncommon causes of shock (like pericardial tamponade). But emergency physicians have all the skills needed to safely handle any trauma airway!
An 18-month old previously well child presents to the emergency department of a community hospital with a head injury following an unwitnessed fall from significant height on a play structure with initial loss of consciousness. He is awake but irritable in the trauma bay, with obvious head injury.
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.
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.
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.
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.