Factoid: Blunt Eye Injury

  1. Corneal abrasion
  2. Anterior hyphema
  3. Traumatic iritis
  4. Traumatic mydriasis
  5. Lens dislocation
  6. Vitreous hemorrhage
  7. Retinal detachment
  8. Ruptured globe
  9. Blow-out fracture of the floor of the orbit

On the goals of resuscitation

What are your goals for this resuscitation? This is one of my favourite questions for medical students and residents when we see and treat critically ill patients. The answers range from the very general (and very correct) ‘my goal is to keep this guy alive’ to the very specific ‘I want to achieve an CVP of 8-12′.  I would argue that the first answer, simple as it is is probably the more correct.

Critically ill patients, be they trauma, sepsis or cardiac arrest are all similar in that they are in physiologically disordered states. Resuscitation for all of these patients is a bridge of survival until a definitive intervention can take effect. The aspects of physiology that are disordered, and the definitive interventions required differ profoundly depending on the nature of the illness, but all of these states share the common ground of being a life threatening disruption of physiologic homeostasis.

The goal of resuscitation I like to think about is the restoration of a physiologically survivable milieux that will bridge the patient’s survival to a definitive intervention. This physiologically survivable milieux includes both measurable and unmeasurable elements. These elements include temperature, O2 carrying capacity, O2 delivery capacity, clotting capacity, pH, electrolyte balance, energy substrate, and cellular metabolic capacity. Our markers of resuscitation, BP, MAP, perfusion, mentation, urinary output, CVP, SCVO2, cardiac index, IVC diameter, or lactate clearance are all imperfect. At best they provide the clinician with a feel for the progress of resuscitation, and at worst they can falsely reassure or mislead.

Our initial response to critically ill patients is often protocol and algorithm driven. Initially this is appropriate, but as the case progresses and the physician gains more information a deeper thought process is required. When confronted with a critically ill patient my first thoughts are often about what definitive intervention I will need to get them to in order to improve their chance of survival. As an emergency physician this may be something I can provide (antibiotics for sepsis) or something I cannot (surgery for trauma). I then like to think about what specific derangements of physiology this particular patient is likely to have, how that threatens their survival, and how (and if) it needs to be corrected.

As emergency physicians we provide a critical link in the chain of survival for critically ill patients. These patients will rarely remember us and rarely thank us, but it is in our hands that they move from undifferentiated critical illness to restoration of a survivable physiological state and a trajectory towards definitive intervention. That, I believe, is the essence of resuscitation.

Factoid: The Airway and Burns

The assessment of the airway is the first priority in evaluation of the burn patient.

  • Upper airway obstruction
  • Inability to handle secretions
  • Hypoxemia despite 100% O2
  • Obtundation/decreased GCS
  • Muscle fatigue suggested by high or low respiratory rate
  • Hypoventilation (PCO2 >50 or pH<7.2
Table 60-3 Rosen’s Emergency Medicine

 

‘Isolated’ Trauma in the Elderly

An 82 year old woman arrives in your emergency room with a shortened and externally rotated hip. She does not remember falling but was found down in the assisted care facility she lives in. The x-ray confirms a displaced sub-capital hip fracture. This is a slam dunk easy case, right? We see this everyday; admit to ortho for ORIF, write some holding orders, (maybe do a 3 in 1 block if you believe in pain control), and move on to the next patient. Right?

Trauma in the elderly is common and we see it everyday. We see hip fractures, wrist fractures and head lacerations usually as a consequence of falls. Those of us in community hospitals may become unaccustomed to dealing with major trauma, as well developed EHS systems tend to route these cases to trauma centres, but the flow of injured elderly continues uninterrupted. In general elderly patients cope poorly with trauma, and have much higher morbidity and mortality than our younger patients, and this is predictable based on burden of concurrent chronic disease and decreased physiological reserve. These patients often have an obvious injury and this is best viewed as a distraction during the first phase of the assessment.

When an elderly patient arrives with what seems to be an isolated traumatic injury resist the temptation to prematurely close the case, and resist the pressure to assess them in the low acuity area of your department. These patients frequently have a more complex story than initially meets the eye.

Our 82 year old patient with a hip fracture is best viewed as a trauma patient, and our assessment should proceed along those lines. The ABCDE approach of ATLS provides a good framework for initial assessment. Additionally there are some important questions you must ask yourself as your assessment proceeds:

  1. Is this patient unstable? Remember elderly patients may not mount a tachycardia, and a ‘normal’ blood pressure may represent relative hypotension.
  2. Does this patient have another injury? Just like in any trauma patient, palpate everything. In particular consider the possibility of c-spine injury, rib fractures, and inter cranial bleeding.
  3. Does this patient have a concurrent disease that will impact or be impacted by their injury? Baseline physiology will impact a patients response to injury, and capacity for recovery.
  4. Does this patient take a medication that will impact or be impacted by this injury? Consider medications that may impact the trauma (ie. anticoagulants), affect the physiological response (ie. beta-blockers, calcium channel blockers, digoxin) or those which may have precipitated the trauma (ie. opioids, benzodiazipines, tricyclic antidepressants).
  5. Is this patients trauma the result of a destabilized/acute medical problem? The cause of trauma is often subtle and discriminating a trip and fall from a syncope is important.
Our 82 year old hip fracture is actually an 82 year old trauma patient. As we would with any trauma patient we should proceed with a complete assessment. we should do a primary survey (ABCDE), protect the C-spine, do a complete secondary survey and ask ourselves the above questions. Ancillary tests should be used liberally. In particular there are few (none) elderly trauma patients who should not have a chest x-ray and ECG. If the patient is altered, anti-coagulated or has external head injury liberal use of CT-head is advisable. The C-spine should also be considered and liberally imaged if tender or the mechanism suggests injury.

 

Trauma is usually portrayed as a dashing specialty area of emergency medicine. Trauma doctors are handsome, poorly shaved and sleep deprived heroes who save the lives of the young and beautiful when they play too hard and drive too fast. As a community emergency doctor I can only assume that this image of big trauma centres, as portrayed on TV, is completely accurate and I wish these heroes all the best, but trauma in my emergency room is often a little bit different.

I am frequently confronted by seemingly simple cases of elderly patients with supposed isolated trauma. By refusing to accept premature closure on these cases, and insisting on running them all as traumas I have been surprised by the frequency with with significant concurrent injury or unstable medical condition is discovered. Inter-cranial haemorrhage and rib fractures are particularly common concurrent injuries, and electrocardiographic explanations for syncope not infrequent. So the next time an elderly injured person arrives in your ambulance bay don’t just close the case and admit to ortho, hunt for injuries, and you will be surprised by what you find.

Your Next Patient #1: A 45 year old man with burns

The following case is meant to simulate an oral examination question. Information will be presented, and the candidate asked to discuss the situation or answer specific questions. The information will be presented sequentially. This is not intended to be a comprehensive topic review, rather it is meant to examine specific candidate competencies.

You are the emergency physician in a medium sized community hospital. Your next patient is a 45 year old man who was in a house fire. He was alone in his bungalow when it caught fire, neighbours found him inside the house, unconscious and partially under some debris and dragged him to safety. The fire department arrived and found the house ‘fully engulfed’. They put oxygen on the patient and brought him to hospital, where is he placed in your resuscitation bay.

The patient has loud respirations and is moaning and rolling about the stretcher. There are obvious facial burns as well as burns on the forearms and hands. The clothes appear to be charred, particularly over the chest. Vital signs are: HR 125 BP 135/75 RR 35 O299% on 10lpm by face mask.

  • The candidate should use an ABCDE approach for the initial part of the assessment
  • The candidate should comment on potential for difficult airway and the importance of securing an early definitive airway
  • The candidate should comment on possibility of thermal injury to the airway
  • The candidate should establish intravenous access and recognize the tachycardia
  • The patient should be fully exposed and the charred clothes removed
  • The patients pain should be addressed
  • A secondary survey should be done in search of other injuries

The airway is secured with an endotracheal tube and there is good bilateral air entry and normal end tidal capnography. Peripheral pulses are present in all 4 limbs. The secondary survey reveals partial and full thickness burns over the face and chest, circumferential burns around the left arm and to the palms of both hands. There is a large area of bruising over the left flank. The vital signs are unchanged.

  • The candidate should be able to calculate the burned body surface area of 24.5%
  • The candidate should calculate an initial fluid regime using the Parkland formula or similar (4ml per %BSA x kg with 50% given over the first 8 hours post injury and the remainder over the next 16 hours)
  • The candidate should be aware that there is potential for other injuries in this patient as evidenced by the flank bruising and respond to this cue
  • The candidate should recognize the potential for circulatory compromise of the left arm and potential need for escharotomy
  • A foley catheter should be placed
  • The candidate should state that this patient requires transfer to a specialized burn centre
  • Appropriate ancillary tests should be obtained (blood gas, co-oximitry, cbc, electrolytes, renal function, lactate, chest and pelvis x-rays, ECG, FAST exam of the abdomen)

  • Partial and full thickness burns >20% BSA, or >10% if age <10 or >50
  • Full thickness burns >5% BSA
  • Burns to special areas: face, eyes, ears, hands, feet, genitalia and perineum, overlying joints
  • Chemical burns
  • Inhalation injury
  • Burns in patients with significant preexisting illness
  • Burns associated with other trauma

A saturation of 99% seems unusually high in a patient with significant inhalation injury. In this case it is worrisome for carbon monoxide toxicity. The patient should be treated with high FiO2 until cooximetery for CO is available.

The patients vital signs remain unchanged. Ancillary tests show the following post intubation blood gas: pH 7.35 PaO2 105 PCO2 35 HC03 22 Base excess -2. CBC, electrolytes and renal function are normal, lactate is 2. X-rays and ECG are normal. FAST is negative.

He is accepted for helicopter transfer to a nearby burn centre.The accepting doctor asks if your local surgeon can do an escharotomy of the arm before transfer and you arrange this. The accepting physician also asks you if you think the patient should be treated for potential cyanide toxicity.

The candidate should discuss the risk factors for cyanide toxicity in fires, especially with reference to household plastics, industrial fires and closed spaces. The candidate should recognize the mechanism of toxicity of cyanide, inactivation of cytochrome A3 oxidase, which uncouples mitochrondrial oxidative phosphorylation shifting cells to anaerobic metabolism. The candidate should recognize that cyanide toxicity results in a significant lactic acidosis. Since our patient has neither acidosis nor elevated lactate significant cyanide toxicity is excluded.

This case examines a candidates competency in managing the initial phase of a straightforward major burn case. The candidate is expected to manage the case in an organized way, such as the ABCDE system from ATLS. It is expected that the candidate will manage the airway and discuss the possible complications. The possibility for other injuries much be recognized and the candidate must make arrangements to move the patient to definitive care. Follow-up questions define the candidates knowledge of criteria that necessitate transfer for burn patients as well as knowledge of potential for carbon monoxide and cyanide toxicity.

This is designed to be a very straightforward oral exam question.