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Geriatric Trauma Competition: SimWars 2020, Cork Round: Final Participants: Undergraduate Medical/Nursing Students. Teams of 5. 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. Scenario Location: Emergency Department, Resus. Patient: Actor (Pain++ but able to give history) Condition: Right Neck of Femur Fracture Winnifred Martin is an 81-year-old lady who was found by a neighbour after an 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 90% RA, HR 124 (irregular), BP 100/70, Temp 35.4 GCS: 12/15 (E4, V3, M5) Appearance: pale, diaphoretic, dyspnoeic but able to converse. Grimaces in pain, guarding abdomen. Past Medical: ?Previous Stroke. Medications: Apixaban, bisoprolol, levothyroxine, lansoprazole, atorvastatin Allergies: NKDA Dr Tiarnán Byrne This work is licensed under a Creative Commons Dr James Condren Attribution-NonCommercial-ShareAlike 4.0 International License Results Exam Cardiac: HS I+II normal, nil added. Heart rate 98 irregularly irregular. Mildly hypotensive Respiratory: Airway normal, RR 20, O2 Sats 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: Right 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. The lesser trochanter is itself fractured and separated from the femur. No abnormalities of the pelvic bones. Osteoarthritic changes in the left hip. Ultrasound – N.A. Progression 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 Hospital Number: MR number: 12345678 Verification Name Winnefred Martin DoB: 02/02/39 Urgent RADIOMETER ABL FLEX 800 Source Accident & Emergency Clinician: Identifications Patient ID tH Full Blood Count Patient Last Name Martin pH White Cell Count 12.2 10*9/L ( 4 - 11 ) Patient First Name Winnefred pH Haemoglobin 93 g/L (115 - 165 ) Sex pH Platelets 130 10*9/L ( 150 - 500 ) Date of Birth RBC 3.7 10*12/L ( 3.8 - 5.8 ) FO2 (l) 21% Haematocrit 0.38 ratio ( 0.37 - 0.47 ) T MCV 60 fl ( 75 - 100 ) Sample type MCH 24 pg ( 26 - 35 ) Operator RDW ( 11.0 - 15.0 ) Blood Gas Values Mean Platelet Volume 7,7 fl ( 7.5 - 9.0 ) ↓ pH 7.32 [ 7.350 - 7.450] WBC Differential ↑ pCO2 6.8 kPa [ 4.70 - 6.00 ] Neutrophils 7.6 10*9/L ( 2.0 - 7.5 ) ↓ pO2 11 kPa [ 11.1 - 14.4 ] Lymphocytes 4.5 10*9/L ( 1.5 - 4.0 ) % Monocytes 1.1 10*9/L ( 0.2 - 1.5 ) Oximetry Values Eosinophils 0,31 10*9/L ( 0.04 - 0.4 ) ↓ ct Hb 91 g/L [ 135 - 175 ] Basophils 0.1 10*9/L ( 0 - 0.1) F O2Hb 96 % [ 94.0 - 98.0 ] sO2 97 % [ 95.0 - 99.0 ] pA Sodium 122 mmol/L ( 133 - 146 ) F CO2Hb 1.4 % [ 0.5 - 1.5 ] pA Potassium 5.7 mmol/L ( 3.5 - 5.3 ) #REF! F HHb 1.3 % [ 0.0 - 1.5 ] pA Urea 14.2 mmol/L ( 2.5 - 7.8) #REF! F MetHb 0.4 % [ 0.0 - 1.5 ] pA Creatinine 203 umol/L ( 49 - 90 ) Calculated Values pA eGFR result/1.73m2 29 ml/min >60 ↓ c Base(Ecf)c -3.3 mmol/L c HCO3 - (P)c mmol/L Electrolyte Values pA CRP 102 mg/L (<5) ↓ c Na + 122 mmol/L [ 136 -146 ] ↑ c K+ 5.5 mmol/L [ 3.4 -4.5 ] Creatinine Kinase 402 iu/l (22-211) c Cl - 102 mmol/L [ 98 -106 ] c Ca 2+ 1.18 mmol/L [ 1.15 - 1.29 ] pA Total Bilirubin 5.2 umol/L ( < 17 ) Anion Gap c mmol/L [ ] pA ALP 27 iu/L ( 25 - 120 ) Metabolite Values pA ALT 18 iu/L ( < 40 ) c Glu 3.3 mmol/L [ 3.0 - 6.0 ] ↑ c Lac 2.8 mmol/L [ 0.5 - 1.6 ] ↑ c Crea 200 umol/L [ 49 - 90 ] …………………………………………………………………………………………………………………………………………………………………………………………………………….. Notes ↑ Value(s) above reference range ↓ Value(s) below reference range c Calculated value(s) Geriatric Trauma - Team Assessment Care Provided 50 Points Marks Marks Criteria Available Awarded Patient Assessment Consider - Systemic approach to assessment/exam - Recognition that patient is acutely unwell. 15 - All medical history obtained - Formation of differentials from medical history + risk factors. Initial Resuscitation Consider - Fluid Bolus - Supplemental Oxygen - Delivery of IV Antibiotic Cover 15 - Catheterisation - Prompt orthopaedic consultation - Pain management/regional anaesthesia Diagnosis Consider - Recognition of probable hip / femur fracture. - Recognise fracture on XR / CT Report 10 - Recognition of potential large bone fracture. - Recognition of potential for intracranial injury, Investigations Consider - Request for CT Brain and Plain film or CT Pelvis. - Bloods (FBC, U&E, ABG/Serum Lactate, amylase, CRP) 5 - Request for group and hold - Blood Cultures - Consideration of FAST/Pelvic Ultrasound. Disposition - Need for urgent surgical intervention and ITU care 5 Geriatric Trauma - Team Assessment Non-Technical Skills 50 Points Marks Marks Criteria Available Awarded Team Work Consider - Coordinating activities. - Exchanging information. 20 - Use of authority & assertiveness - Assessing capabilities - Supporting others Task Management Consider - Planning & preparing - Prioritising 10 - Providing & maintaining standards - Identifying & utilising resources Situation Awareness Consider - Gathering information 10 - Recognising & understanding - Anticipating Decision Making Consider - Identifying options - Balancing risks & selecting options 10 - Re-evaluating