Trauma in the Emergency Room
Content
TRAUMA IN THE EMERGENCY ROOM, DR PHILIP STOKOE THE CALGARY SCHEME CAMBRIGE 1. 2. 3. 4. 5. Initiating the session Gathering information Physical examination Explanation and planning Closing the session
POMR - Problem Medical Record
oriented A. History Fall Head injury Headache Difficulty in walking Semi-conscious HISTORY TAKING SEQUENCE 1. Presenting Symptoms (PS) 2. History of Presenting Illness (HPI) 3. Past History (PH) 4. Social History (SH) 5. Family History (FH) 6. System Review (SR)
Past history Hypertension Treatment Diabetes mellitus Drug addict Alcohol use C. Exam D. Differential diagnosis DIFFERENTIAL DIAGNOSIS FROM SYMPTOMS/SIGNS: A. Neurological systems and mental state A. Do you get headache? B. Is your headache very severe and did it begin very suddenly? Sub-arachnoid haemorrhage C. Have you had memory problems or trouble concentrating D. Have you had fainting episodes, fits or blackouts? E. Do you have trouble seeing or hearing? F. Are you dizzy?
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B. Epilepsy • Genetic • Head trauma • Intra cranial tumours • Strokes • Abcess • Alcohol • Drugs • Uraemia C. Unconsciousness • Boggy scalp swelling • Depression cranium • Alcohol breath • Needle marks • Hepatomegaly • Hypertension/hypotension • Diabetic coma – sweet breath E. Initial problem related plans Imaging Blood Exam Monitoring Tests Treatment
PROGRESS NOTES: • S: Subjective • O: Objective • A: Assessment • P: Plan
FLOW CHART Dx : Diagnostic Test Mx: Monitoring Test Rx: Treatment Ed: Education Blood exam Continuous Blood Tests Glasgow scale IV fluids Consultation Imaging Second Imaging O2 Patient Advice Family Advice
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COMA
GRADING OF COMA: 1. Alert 2. Drowsy but responds to verbal stimulation 3. Unconscious – no response to verbal stimulation, but withdrawal response to pain 4. Unconscious – decorticate responses to pain (flexion of upper limb and extension of lower limb) 5. Unconscious – decerebrate responses to pain (hyperextension of both upper and lower limbs) 6. Unconscious p no response to pain GLASGOW COMA SCALE: Patient’s response Eye opening Spontaneous To speech To pain None Best verbal responses Oriented Confused Inappropriate Incomprehensible None Best motor responses Obeying Localising Withdrawing Flexing Extending None Score 4 3 2 1 5 4 3 2 1 6 5 4 3 2 1 08.00 10.00 12.00
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SYMPTOMS/SIGNS OF COMA: • Take history if possible • Assess level of consciousness – use Glasgow coma scale but remember its limitations • Look for sings of meningeal irritation • Assess pupils • Assess ocular movements, if necessary using doll’s head manoeuvre • Assess motor responses • Assess respiration • Perform a general physical examination, including the heart, abdomen and skull CRITERIA FOR BRAIN DEATH: • Dilated pupils • No corneal response • Vestibular ocular reflex • Motor response to painful stimulus to glabella • No gag response to tracheal response • Steroterious breathing THE UNCONSCIOUS PATIENT: • C –CO2 narcosis (respiratory failure: uncommon) • O – Overdose: for example, trangquillisers, alcohol, salicylates, carbon monoxide, antidepressants • M- Metabolic: for example, hypoglycaemia, diabetic ketoacidosis, uraemia, hypothyroidism, hepatic coma, hypercalcaemia, adrenal failure • A- Apoplexy: for example, head injury, cerebrovascular accident (infarction or haemorrhage), subdural or extradural haematoma, meningitis, encephalitis, epilepsy GENERAL INSPECTION TRAUMA PATIENT Remember A-B-C: Airway, Breathing and Circulation OF Airway and Breathing: Look to see if the patient is breathing, as indicated by chest wall movement. If not, urgent attention is required, including clearing the airway and providing ventilation. Note particularly the pattern of breathing. Cheyne Stokes respiration (which may indicate diencephalic injury, but is not specific), irregular ataxic breathing (Biot’s breathing, from an advanced brainstem lesion), and deep rapid respiration (e.g. Kussmaul breathing, secondary to a metabolic acidosis, as in diabetes mellitus) are important signs to look for. Circulation : Look for signs of shock, dehydration and cyanosis. A typical cherry-red colour occurs rarely in cases of carbon monoxide poisoning. Take the pulse rate and blood pressure.
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POMR - Problem Medical Record
oriented A. History Fall Head injury Headache Difficulty in walking Semi-conscious HISTORY TAKING SEQUENCE 1. Presenting Symptoms (PS) 2. History of Presenting Illness (HPI) 3. Past History (PH) 4. Social History (SH) 5. Family History (FH) 6. System Review (SR)
Past history Hypertension Treatment Diabetes mellitus Drug addict Alcohol use C. Exam D. Differential diagnosis DIFFERENTIAL DIAGNOSIS FROM SYMPTOMS/SIGNS: A. Neurological systems and mental state A. Do you get headache? B. Is your headache very severe and did it begin very suddenly? Sub-arachnoid haemorrhage C. Have you had memory problems or trouble concentrating D. Have you had fainting episodes, fits or blackouts? E. Do you have trouble seeing or hearing? F. Are you dizzy?
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B. Epilepsy • Genetic • Head trauma • Intra cranial tumours • Strokes • Abcess • Alcohol • Drugs • Uraemia C. Unconsciousness • Boggy scalp swelling • Depression cranium • Alcohol breath • Needle marks • Hepatomegaly • Hypertension/hypotension • Diabetic coma – sweet breath E. Initial problem related plans Imaging Blood Exam Monitoring Tests Treatment
PROGRESS NOTES: • S: Subjective • O: Objective • A: Assessment • P: Plan
FLOW CHART Dx : Diagnostic Test Mx: Monitoring Test Rx: Treatment Ed: Education Blood exam Continuous Blood Tests Glasgow scale IV fluids Consultation Imaging Second Imaging O2 Patient Advice Family Advice
2 dr.sailormoon_danke@copyright_Emergency & Traumatology2011
COMA
GRADING OF COMA: 1. Alert 2. Drowsy but responds to verbal stimulation 3. Unconscious – no response to verbal stimulation, but withdrawal response to pain 4. Unconscious – decorticate responses to pain (flexion of upper limb and extension of lower limb) 5. Unconscious – decerebrate responses to pain (hyperextension of both upper and lower limbs) 6. Unconscious p no response to pain GLASGOW COMA SCALE: Patient’s response Eye opening Spontaneous To speech To pain None Best verbal responses Oriented Confused Inappropriate Incomprehensible None Best motor responses Obeying Localising Withdrawing Flexing Extending None Score 4 3 2 1 5 4 3 2 1 6 5 4 3 2 1 08.00 10.00 12.00
3 dr.sailormoon_danke@copyright_Emergency & Traumatology2011
SYMPTOMS/SIGNS OF COMA: • Take history if possible • Assess level of consciousness – use Glasgow coma scale but remember its limitations • Look for sings of meningeal irritation • Assess pupils • Assess ocular movements, if necessary using doll’s head manoeuvre • Assess motor responses • Assess respiration • Perform a general physical examination, including the heart, abdomen and skull CRITERIA FOR BRAIN DEATH: • Dilated pupils • No corneal response • Vestibular ocular reflex • Motor response to painful stimulus to glabella • No gag response to tracheal response • Steroterious breathing THE UNCONSCIOUS PATIENT: • C –CO2 narcosis (respiratory failure: uncommon) • O – Overdose: for example, trangquillisers, alcohol, salicylates, carbon monoxide, antidepressants • M- Metabolic: for example, hypoglycaemia, diabetic ketoacidosis, uraemia, hypothyroidism, hepatic coma, hypercalcaemia, adrenal failure • A- Apoplexy: for example, head injury, cerebrovascular accident (infarction or haemorrhage), subdural or extradural haematoma, meningitis, encephalitis, epilepsy GENERAL INSPECTION TRAUMA PATIENT Remember A-B-C: Airway, Breathing and Circulation OF Airway and Breathing: Look to see if the patient is breathing, as indicated by chest wall movement. If not, urgent attention is required, including clearing the airway and providing ventilation. Note particularly the pattern of breathing. Cheyne Stokes respiration (which may indicate diencephalic injury, but is not specific), irregular ataxic breathing (Biot’s breathing, from an advanced brainstem lesion), and deep rapid respiration (e.g. Kussmaul breathing, secondary to a metabolic acidosis, as in diabetes mellitus) are important signs to look for. Circulation : Look for signs of shock, dehydration and cyanosis. A typical cherry-red colour occurs rarely in cases of carbon monoxide poisoning. Take the pulse rate and blood pressure.
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