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28 Cards in this Set

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Case #1:
A 19-year-old male is brought to the ER by ambulance after being shot in the abdomen 20 minutes earlier in a bar. On arrival, he is diaphoretic, pale, cold, shivering, anxious; he asks for a blanket and water. Initial survey confirms the presence of an entry wound in the mid-epigastrium, a blood pressure of 75/60, and a feeble pulse rate of 142.
Diagnosis: Hemorrhagic shock
• Most common shock post trauma: hypovolemic (hemorrhagic)
• If trauma to the chest occurs: must also consider pericardial tamponade and tension pneumothorax. Look for elevated CVP and distended neck veins.
Case #1:
A 19-year-old male is brought to the ER by ambulance after being shot in the abdomen 20 minutes earlier in a bar. On arrival, he is diaphoretic, pale, cold, shivering, anxious; he asks for a blanket and water. Initial survey confirms the presence of an entry wound in the mid-epigastrium, a blood pressure of 75/60, and a feeble pulse rate of 142.
Management:
Management:

• If possible, control bleeding first and then fill up vascular tree
• Immediate laparotomy preceded by big bore IV lines, Foley catheter and IV antibiotics
• Once bleeders clamped, rapid infusion of Ringers lactate and packed RBC’s
Case #2:
A car accident victim arrives in the ER. Initial survey shows that he is fully conscious and speaking with a normal tone of voice, but he is also pale, perspiring and shivering. He is breathing well and his head and neck veins are not distended. Blood pressure is 85/62 and there is a barely perceptible pulse at a rate of 115 per min.

Diagnosis:
Diagnosis: Hemorrhagic shock
• Unlike case 1 with penetrating injury, this patient sustained blunt trauma, perhaps to the chest. Must r/o pericardial tamponade and tension pneumothorax.
• Normal JVD and breathing r/o both. Again, hemorrhagic shock is most likely diagnosis.
Case #2:
A car accident victim arrives in the ER. Initial survey shows that he is fully conscious and speaking with a normal tone of voice, but he is also pale, perspiring and shivering. He is breathing well and his head and neck veins are not distended. Blood pressure is 85/62 and there is a barely perceptible pulse at a rate of 115 per min.
Management:
Management:
• Remember ABC’s. Source of bleeding unknown; can’t use the “stop bleeding first, replace volume later approach”
• Two large peripheral IV lines with a couple of liters of Ringer’s lactate (no sugar) infused over 20-30 minutes
Case #3:
An ambulance arrives at the site where a car ran into a tree on a remote rural road. The lone occupant of the vehicle is cold, pale, perspiring and shivering. His blood pressure is 80/60, his pulse rate is 120, and he has no visible distended veins in his head and neck. The nearest hospital is at least an hour away.

Diagnosis:
Diagnosis: Hemorrhagic shock
Case #3:
An ambulance arrives at the site where a car ran into a tree on a remote rural road. The lone occupant of the vehicle is cold, pale, perspiring and shivering. His blood pressure is 80/60, his pulse rate is 120, and he has no visible distended veins in his head and neck. The nearest hospital is at least an hour away.
Management:
Hemorrhagic shock
Management:
• Infuse Ringer’s lactate while in transit to the hospital
Case #4:
An innocent bystander is shot in the chest and abdomen during a botched bank robbery. On arrival in the ER he is pale, diaphoretic, cold, shivering, anxious, and thirsty. He has bilateral breath sounds and is breathing well, but he has large distended veins in his neck and forehead. His blood pressure is 65/45, and his pulse rate is 150.

Diagnosis:
Case #4:
An innocent bystander is shot in the chest and abdomen during a botched bank robbery. On arrival in the ER he is pale, diaphoretic, cold, shivering, anxious, and thirsty. He has bilateral breath sounds and is breathing well, but he has large distended veins in his neck and forehead. His blood pressure is 65/45, and his pulse rate is 150.
________________________________________
Diagnosis: Cardiogenic shock due to pericardial tamponade
• Can r/o tension pneumothorax because he has normal breath sounds and is breathing well
• By exclusion, correct diagnosis is pericardial tamponade
Case #4:
An innocent bystander is shot in the chest and abdomen during a botched bank robbery. On arrival in the ER he is pale, diaphoretic, cold, shivering, anxious, and thirsty. He has bilateral breath sounds and is breathing well, but he has large distended veins in his neck and forehead. His blood pressure is 65/45, and his pulse rate is 150.
Management:
Management:
• Pericardial tamponade is a clinical diagnosis; do not need further diagnostic studies
• CXR and EKG NOT merited; in an unclear case, would order sonogram
• Must evacuate blood from pericardial sac
• Give patient blood or IV fluids despite high venous pressure as elevated pressure due to mechanical impediment to ventricular filling, not ventricular failure
Case #5:
A 23-year-old gang member arrives at the ER with multiple gun shot wounds to the chest. Breathing is labored, nostrils flared, and he has big distended veins in his neck and forehead. He is pale, cold, sweating, shivering, and mumbles that he is going to die. Initial survey shows a blood pressure of 60/40, barely perceptible pulse at a rate of 150, and a right hemithorax that is hyperresonant to percussion and devoid of breath sounds. Palpation of the trachea shows it to be deviated toward the left.

Diagnosis:
Diagnosis:
Tension pneumothorax
Case #5:
A 23-year-old gang member arrives at the ER with multiple gun shot wounds to the chest. Breathing is labored, nostrils flared, and he has big distended veins in his neck and forehead. He is pale, cold, sweating, shivering, and mumbles that he is going to die. Initial survey shows a blood pressure of 60/40, barely perceptible pulse at a rate of 150, and a right hemithorax that is hyperresonant to percussion and devoid of breath sounds. Palpation of the trachea shows it to be deviated toward the left.
Management:
Tension pneumothorax
Management:
• Clinical diagnosis of a life-threatening emergency: getting a CXR or waiting for ABG results would be a deadly mistake
• Large bore needle or IV catheter into 2nd intercostal space
• Chest tube to follow
Case #6:
During a round of golf, a business executive is hit on the right side of his head with a golf ball. He loses consciousness for a few minutes, but wakes up promptly and continues to play. 1 hour later he is found unconscious in the locker room. His right pupil is fixed and dilated, and he has contralateral hemiparesis.

Diagnosis:
Diagnosis: Epidural hematoma
• Sequence of trauma, coma, lucid period, coma again, ipsilateral fixed dilated pupil and contralateral hemiparesis suggests acute intracranial hematoma with displacement of the midline structures.

Diagnosis: Epidural hematoma
• Epidural vs. subdural: subdural requires a much bigger trauma and presents with a sicker patient.
• Blow to side of head where middle meningeal artery lies, as well as the very lucid “lucid interval” suggests acute epidural bleed.
• In 90% of cases dilated pupil on same side as hematoma.
Case #6:
During a round of golf, a business executive is hit on the right side of his head with a golf ball. He loses consciousness for a few minutes, but wakes up promptly and continues to play. 1 hour later he is found unconscious in the locker room. His right pupil is fixed and dilated, and he has contralateral hemiparesis.
Management:
Management:
• CT scan of head to confirm location (right vs. left; epidural vs. subdural)
• Biconcave epidural hematoma on the right; deviation of midline structures to the left
• Cranionotomy and decompression
Case #7:
The front seat passenger of a car involved in a high-speed, head-on collision, arrives in the ER in a deep coma. The EMTs report that he was unconscious at the site, woke up briefly in the ambulance, and then lapsed into a coma again. His right pupil is fixed and dilated and he has signs of contralateral hemiparesis with decerebrate posture.

Diagnosis:
Diagnosis: Acute subdural hematoma
• Severity of trauma and profound neurological deficits suggest acute subdural hematoma, probably on the right side.
Case #7:
The front seat passenger of a car involved in a high-speed, head-on collision, arrives in the ER in a deep coma. The EMTs report that he was unconscious at the site, woke up briefly in the ambulance, and then lapsed into a coma again. His right pupil is fixed and dilated and he has signs of contralateral hemiparesis with decerebrate posture.
Management:
Management: Diagnosis: Acute subdural hematoma
• Head CT
• Semilunar, crescent-shaped hematoma on the right; deviation of the midline structures to the left
• Deviation provides rationale for surgery; without displacement more conservative approach with ICP management
• With major blunt trauma to the head, remember to check the C-spine
Case #7:
The front seat passenger of a car involved in a high-speed, head-on collision, arrives in the ER in a deep coma. The EMTs report that he was unconscious at the site, woke up briefly in the ambulance, and then lapsed into a coma again. His right pupil is fixed and dilated and he has signs of contralateral hemiparesis with decerebrate posture.
Management:
Diagnosis:
Acute subdural hematoma
Management:
• Head CT
• Semilunar, crescent-shaped hematoma on the right; deviation of the midline structures to the left
• Deviation provides rationale for surgery; without displacement more conservative approach with ICP management
• With major blunt trauma to the head, remember to check the C-spine
Case #8:
An 82-year-old alcoholic man is rummaging under the sink looking for his last bottle of cheap wine. While doing so, he bumps his head against the counter, but suffers no apparent injury. Over the next week, however, he gradually loses his mental capacities, and becomes obtunded and disoriented.

Diagnosis:
Diagnosis: Chronic subdural hematoma
• Shrinkage of brain (but not skull) in old people and alcoholics
• Torn venous sinuses with slow venous bleeding
Case #8:
An 82-year-old alcoholic man is rummaging under the sink looking for his last bottle of cheap wine. While doing so, he bumps his head against the counter, but suffers no apparent injury. Over the next week, however, he gradually loses his mental capacities, and becomes obtunded and disoriented.

Management:
Diagnosis: Chronic subdural hematoma
Management:
• CT scan of the head
• Evacuation of clot
Case #9:
A 18-year-old male is stabbed in the right chest. He presents moderately short of breath, but his other vital signs are stable. Physical examination reveals an absence of breath sounds in the right hemithorax, which sounds hyperresonant to percussion.
Diagnosis:
Diagnosis: Pneumothorax
Case #9:
A 18-year-old male is stabbed in the right chest. He presents moderately short of breath, but his other vital signs are stable. Physical examination reveals an absence of breath sounds in the right hemithorax, which sounds hyperresonant to percussion.
Diagnosis: Pneumothorax
Management:
• Not life-and-death; time to confirm with studies
• CXR will confirm diagnosis and show extent of pneumothorax and whether there is blood in the pleural space
• Chest tube
Case #10:
A 20-year-old male is stabbed in the right chest. He is moderately short of breath, but his other vital signs are stable. Physical exam reveals no breath sounds at the right base, and faint, distant breath sounds at the right apex. Right side of his chest is dull to percussion. A CXR shows blood in the right pleural space, and a chest tube is placed at the right pleural base. The tube initially recovers 270 cc of blood, drains another 35 cc in the next hour, and 12 cc in the second hour.
Diagnosis:
Diagnosis: Hemothorax
• Bleeding from penetrating chest injuries most often from lung
Case #10:
A 20-year-old male is stabbed in the right chest. He is moderately short of breath, but his other vital signs are stable. Physical exam reveals no breath sounds at the right base, and faint, distant breath sounds at the right apex. Right side of his chest is dull to percussion. A CXR shows blood in the right pleural space, and a chest tube is placed at the right pleural base. The tube initially recovers 270 cc of blood, drains another 35 cc in the next hour, and 12 cc in the second hour.
Management:
Diagnosis: Hemothorax
• Bleeding from penetrating chest injuries most often from lung
Management:
• While bleeding will stop by itself, expectant therapy not advisable because contaminated blood in the pleural space may produce empyema
• Evacuation of blood is imperative
• One or more chest tubes placed and not removed until no blood draining
• Surgery seldomly required
Case #11:
A 19-year-old male is stabbed in the right chest. On arrival at the ER he is short of breath, pale, with a pulse rate of 95 and a blood pressure of 90/70. His right hemithorax has no breath sounds and is dull to percussion. CXR shows the entire pleural space to be filled with blood. When a chest tube is inserted, 1600 cc of blood are recovered.
Diagnosis and Management:
Diagnosis and Management:
• Hemothorax with systemic vessel bleeding (usually intercostals)
• Emergency thoracotomy to control bleeding
• Vigorous fluid and blood replacement
Case #12:
A 45-year-old woman involved in a car accident in which 3 other passengers died arrives at the ER. She is moderately short of breath, but her other vital signs are stable. Initial survey shows multiple bruises and minor lacerations, but the most impressive finding is the presence of at least 8 rib fractures on the right side of her chest, and a very peculiar physical finding: there is an area of the chest wall on the right that caves in whenever she inspires and bulges out on expiration.
Diagnosis:
Diagnosis:
• Consider: severe trauma to the chest, deceleration injury
• Think of obvious injuries as well as hidden ones
• Broken ribs and flail chest are obvious
• Consider possibility of traumatic rupture of aorta
• Manage the obvious, uncover the hidden
Case #12:
A 45-year-old woman involved in a car accident in which 3 other passengers died arrives at the ER. She is moderately short of breath, but her other vital signs are stable. Initial survey shows multiple bruises and minor lacerations, but the most impressive finding is the presence of at least 8 rib fractures on the right side of her chest, and a very peculiar physical finding: there is an area of the chest wall on the right that caves in whenever she inspires and bulges out on expiration.
Management:
Management:
• Deal with broken ribs first: local nerve blocks
• Flail chest: contused lung exquisitely sensitive to fluid overload; limit fluid infusion and use colloids rather than crystalloids; maybe add diuretics
• Monitor blood gases for respiratory failure
• If she requires a respirator, must also insert prophylactic chest tubes
• Check CXR for aortic transection; wide mediastinum leads to aortogram. If mediastinum not widened, spiral CT or transesophageal echo
Case #13:
A 23-year-old man crashes his car into a wall. When he arrives at the ER, a mirror image of the word “Ford” can be seen imprinted as a bruise over his precordial region. He is exquisitely tender at a point in the sternum, where palpation elicits a gritty feeling of bone grating on bone.
Diagnosis: Management:
• CXR will reveal sternal fracture and can check for widened mediastinum
• Diagnosis and management of myocardial contusion similar to MI; EKG more reliable than enzymes
Diagnosis: Sternal fracture
• Probable myocardial contusion
• Fracture of hard-to-break bones (sternum, scapula, first rib) suggest major trauma
• Sudden deceleration chest trauma- possibility of aortic rupture
Case #13:
A 23-year-old man crashes his car into a wall. When he arrives at the ER, a mirror image of the word “Ford” can be seen imprinted as a bruise over his precordial region. He is exquisitely tender at a point in the sternum, where palpation elicits a gritty feeling of bone grating on bone.
Management:
Management:
• CXR will reveal sternal fracture and can check for widened mediastinum
• Diagnosis and management of myocardial contusion similar to MI; EKG more reliable than enzymes
Case #14:
Two airplanes collide on runway and there are multiple casualties. One of the survivors is found walking around in a daze, but otherwise seemingly unharmed. Over his objections, he is taken to the hospital, where a CXR shows a wide mediastinum and a fractured left first rib.
Diagnosis:
Diagnosis: Traumatic rupture of aorta
• Intima and media may have cracked and be asymptomatic until adventitia gives way
Case #14:
Two airplanes collide on runway and there are multiple casualties. One of the survivors is found walking around in a daze, but otherwise seemingly unharmed. Over his objections, he is taken to the hospital, where a CXR shows a wide mediastinum and a fractured left first rib.
Management:
• Aortogram
• Widened mediastinum on CXR not sufficient to rush to surgery; could be mediastinal hematoma from other causes
Management:
• Aortogram
• Widened mediastinum on CXR not sufficient to rush to surgery; could be mediastinal hematoma from other causes