Geriatric Trauma S cena rio Dr Tiarn á n Byrne Dr James Condren This work is licensed under a Creative Commons Attribution - NonCommercial - ShareAlike 4.0 International License Participants: Undergraduate Medical/Nursing Students. Teams of 5. Competition: SimWars 2020, Cork Round: Final Learning Objectives • Identification of geriatric falls patient as ‘major trauma’. • Use of ABCDE/primary survey and secondary survey approach • Identification of Neck of Femur Fracture • General principles for management of neck of femur fractures. • Teamwork and communication. Location: Emergency Department , Resus. Patient: Actor (Pain++ but able to give history) Condition: Right Neck of Femur F racture Winnifred Martin is an 81 - year - old lady who was found by a neighbour after a n apparent fall. She was found lying at the back door of her house in a confused state. She is now disorientated and unable to weight bear on her right leg . According to the neighbour Winnifred often steps outside to smoke but has had memory and mobility issues since suffering a stroke a number of years ago. It is not known what time she fell. Her medical notes are not immediately available, but paramedics have brought a blister pack of medications from her home. Initial Observations: RR 20 , Sp02 9 0 % RA, HR 124 ( ir regular) , BP 10 0 / 70, Temp 3 5. 4 GCS: 1 2 /15 (E4, V 3 , M5) Appearance : pale, diaphor etic , dyspnoeic but able to converse G rimaces in pain , guarding abdomen. Past Medical: ?Previous Stroke. Medications: Apixaban , bisoprolol, l evothyroxine , lansoprazole , atorvastatin Allergies: NKDA Exam Results Cardiac: HS I+II normal, nil added. Heart rate 98 irregularly ir regular. Mildly hypotensive Respiratory: Airway normal, RR 20 , O2 S ats 90% on RA. Bilateral wheeze and scattered crepitations Gastrointestinal: Abdomen Soft and non - tender Neuro: GCS 12/15 (E4, V3, M5). Reduced power in the left limbs (4/5). Unable to assess right lower limb due to pain. PEARLA. No other neurological deficits. MSK: Ri ght leg shortened, abducted and externally rotated. Unable to tolerate range of movement exam if attempted. Pain on palpation of the greater trochanter. No long bone tenderness. Circulation, sensation and movement present in all limbs. Other: Small haematoma to left forehead. Investigations ECG: Atrial Fibrillation Portable CXR – Hyperinflation, chronic inflammatory changes. XR Rt Hip : Comminuted subtrochanteric fracture (inferior to the greater and lesser trochanters). The proximal fragment appears abducted. The lesser trochanter is itself fractured and separated from the femur. CT (as ordered) • Brain: Changes consistent with old right sided infarct and noted on CT Brain 5 years ago. No evidence of intracranial bleeding. • Thorax: Bilateral bronchial wall thickening and air trapping consistent with Chronic Obstructive Pulmonary Disease. • Abdomen: Multiple large bowel adhesions, no evidence of obstruction. Uterus and ovaries absent. Calculi present in gallbladder. • Pelvis: Comminuted subtrochanteric fracture (inferior to the greater and lesser trochanters). The proximal fragment abducted. T he lesser trochanter is itself fractured and separated from the femur. No abnormalities of the pelvic bones. Osteoarthritic changes in the left hip Ultraso und – N.A. P rogression With Appropriate Resuscitation Time 00:00 00:02 00:04 00:06 00:08 10:00 Condition Alert Verbal Verbal Verbal Verbal Verbal Pulse 124 118 120 108 90 94 BP 100/50 105/60 108/72 110/70 109/74 115/72 Sp02 90% on RA 90% on O2 92% on O2 94% on O2 96% on O2 94% on O2 RR 20 18 18 16 16 16 Without Appropriate Resuscitation Time 00:00 00:02 00:04 00:06 00:08 10:00 Condition Alert Verbal Pain Pain Pain Pain Pulse 124 126 124 132 144 140 BP 105/65 100/60 90/45 88/40 88/42 88/42 Sp02 90% on RA 88% RA 86% on RA 84% on RA 84% on RA 84% on RA RR 20 20 22 26 28 26 Image CardioNetworks via WikiCommons https://bit.ly/2vyX8ne Right Hip XR Source: Radiopedia. Case courtesy of Dr Bruno Di Muzio , Radiopaedia.org, rID: 39409 R A D I O M E T E R A B L F L E X 8 0 0 I d e n t i f i c a t i o n s P a t i e n t I D P a t i e n t L a s t N a m e M a r t i n P a t i e n t F i r s t N a m e W i n n e f r e d S e x D a t e o f B i r t h F O 2 ( l ) 2 1 % T S a m p l e t y p e O p e r a t o r B l o o d G a s V a l u e s ↓ p H 7 3 2 [ 7 3 5 0 - 7 4 5 0 ] ↑ p C O 2 6 8 k P a [ 4 7 0 - 6 0 0 ] ↓ p O 2 1 1 k P a [ 1 1 1 - 1 4 4 ] % O x i m e t r y V a l u e s ↓ c t H b 9 1 g / L [ 1 3 5 - 1 7 5 ] F O 2 H b 9 6 % [ 9 4 0 - 9 8 0 ] s O 2 9 7 % [ 9 5 0 - 9 9 0 ] F C O 2 H b 1 4 % [ 0 5 - 1 5 ] # R E F ! F H H b 1 3 % [ 0 0 - 1 5 ] # R E F ! F M e t H b 0 4 % [ 0 0 - 1 5 ] C a l c u l a t e d V a l u e s ↓ c B a s e ( E c f ) c - 3 3 m m o l / L c H C O 3 - ( P ) c m m o l / L E l e c t r o l y t e V a l u e s ↓ c N a + 1 2 2 m m o l / L [ 1 3 6 - 1 4 6 ] ↑ c K + 5 5 m m o l / L [ 3 4 - 4 5 ] c C l - 1 0 2 m m o l / L [ 9 8 - 1 0 6 ] c C a 2 + 1 1 8 m m o l / L [ 1 1 5 - 1 2 9 ] A n i o n G a p c m m o l / L [ ] M e t a b o l i t e V a l u e s c G l u 3 3 m m o l / L [ 3 0 - 6 0 ] ↑ c L a c 2 8 m m o l / L [ 0 5 - 1 6 ] ↑ c C r e a 2 0 0 u m o l / L [ 4 9 - 9 0 ] ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... N o t e s ↑ V a l u e ( s ) a b o v e r e f e r e n c e r a n g e ↓ V a l u e ( s ) b e l o w r e f e r e n c e r a n g e c C a l c u l a t e d v a l u e ( s ) H o s p i t a l N u m b e r : M R n u m b e r : 1 2 3 4 5 6 7 8 V e r i f i c a t i o n N a m e W i n n e f r e d M a r t i n D o B : 0 2 / 0 2 / 3 9 U r g e n t S o u r c e A c c i d e n t & E m e r g e n c y C l i n i c i a n : tH Full Blood Count pH White Cell Count 1 2 2 1 0 * 9 / L ( 4 - 1 1 ) pH Haemoglobin 9 3 g / L ( 1 1 5 - 1 6 5 ) pH Platelets 1 3 0 1 0 * 9 / L ( 1 5 0 - 5 0 0 ) RBC 3 7 1 0 * 1 2 / L ( 3 8 - 5 8 ) Haematocrit 0 3 8 r a t i o ( 0 3 7 - 0 4 7 ) MCV 6 0 f l ( 7 5 - 1 0 0 ) MCH 2 4 p g ( 2 6 - 3 5 ) RDW ( 1 1 0 - 1 5 0 ) Mean Platelet Volume 7 , 7 f l ( 7 5 - 9 0 ) WBC Differential Neutrophils 7 6 1 0 * 9 / L ( 2 0 - 7 5 ) Lymphocytes 4 5 1 0 * 9 / L ( 1 5 - 4 0 ) Monocytes 1 1 1 0 * 9 / L ( 0 2 - 1 5 ) Eosinophils 0 , 3 1 1 0 * 9 / L ( 0 0 4 - 0 4 ) Basophils 0 1 1 0 * 9 / L ( 0 - 0 1 ) pA Sodium 1 2 2 m m o l / L ( 1 3 3 - 1 4 6 ) pA Potassium 5 7 m m o l / L ( 3 5 - 5 3 ) pA Urea 1 4 2 m m o l / L ( 2 5 - 7 8 ) pA Creatinine 2 0 3 u m o l / L ( 4 9 - 9 0 ) pA eGFR result/1.73m2 2 9 m l / m i n > 6 0 pA CRP 1 0 2 m g / L ( < 5 ) Creatinine Kinase 4 0 2 i u / l ( 2 2 - 2 1 1 ) pA Total Bilirubin 5 2 u m o l / L ( < 1 7 ) pA ALP 2 7 i u / L ( 2 5 - 1 2 0 ) pA ALT 1 8 i u / L ( < 4 0 ) Geriatric Trauma - Team Assessment Care Provided 50 Points Criteria Marks Available Marks Awarded Patient Assessment Consider - Systemic approach to assessment/exam - Recognition that patient is acutely unwell. - All medical history obtained - Formation of differentials from medical history + risk factors 15 Initial Resuscitation Consider - Fluid Bolus - Supplemental Oxygen - Delivery of IV Antibiot ic Cover - Catheterisation - Promp t orthopaedic consultation - Pain management/regional anaesthesia 1 5 Diagnosis Consider - Recognition of probable hip / femur fracture. - Recognise fracture on XR / CT Report - Recognition of potential large bone fracture. - Recognition of potential for intracranial injury, 10 Investigations Consider - Request for CT Brain and Plain film or CT Pelvis - Bloods (FBC, U&E, A BG/Serum Lact ate, amylase , CRP) - Request for group and hold - Blood Cultures - Consideration of FAST/Pelvic Ultrasound. 5 Disposition - Need for urgent surgical intervention and ITU care 5 Geriatric Trauma - Team Assessment Non - Technical Skills 50 Points Criteria Marks Available Marks Awarded Team Work Consider - Coordinating activities - Exchanging information - Use of authority & assertiveness - Assessing capabilities - Supporting others 20 Task Management Consider - Planning & preparing - Prioritising - Providing & maintaining standards - Identifying & utilising resources 10 Situation Awareness Consider - Gathering information - Recognising & understanding - Anticipating 10 Decision Making Consider - Identifying options - Balancing risks & selecting options - Re - evaluating 10