Geriatric Trauma Competition: Virtual SimWars 2021, Limerick Round: Semi-Final Participants: Undergraduate Medical/Nursing Students. Team of 5. Learning Objectives ● Identification of geriatric falls patients as ‘major trauma’. ● Use of ABCDE/primary survey and secondary survey approach. ● Identification of serious injury from low energy injury Scenario Location: Emergency Department. (Virtual Learning Environment) Patient: Actor (Pain++ but able to give history) Condition: Head Injury on Anticoagulation Tom Byrne is a 77-year-old man who had an unwitnessed fall while shopping in a supermarket around 4 hours ago. A bystander said he was found lying on the ground in the alcohol section. Initially he seemed disorientated but this appeared to settle and he refused transport to hospital. He has now been brought into the emergency department by his wife who wants him to be “checked out” as he has been complaining of a headache all afternoon. She informs you that he has a history of cognitive impairment, COPD and takes a blood thinner called Dabigatran for an “irregular heartbeat”. He is an ex-smoker and enjoys a ‘tipple’ of whiskey most evenings. There is no list of medications available. Initial Observations: RR 20, Sp02 90% RA, HR 124 (irregular), BP 160/90, Temp 37.3 GCS: 14/15 (E4, V4, M6) Past Medical: Cognitive Impairment, COPD, Arrhythmia. Allergies: NKDA Results Examination Cardiac: HS I+II normal, nil added. Heart rate 124 irregularly irregular. Respiratory: Airway normal, RR 20, O2 Sats 90% on RA. Bilateral wheeze and scattered crepitations Gastrointestinal: Abdomen Soft and non-tender Neuro: GCS 14/15 (E4, V4, M6). Orientated to person gives incorrect place (library), month and year. Left pupil is dilated and nonreactive to light. Other pupil is of normal size and reacts to light. Rest of the neurological exam in normal. MSK: Midline tenderness over C4 and C5 vertebrae. Other: Small haematoma to right forehead. Investigations ECG: Atrial Fibrillation Portable CXR – Hyperinflation, chronic inflammatory changes. CT Brain - No-report available during scenario. Large, acute Sub-dural haemorrahage. Images from https://radiopaedia.org/cases/subdural-haemorrhage-on-warfarin-1 CT C-Spine - Verbal report from Radiology Reg - acute undisplaced # of C4/5 vertebral bodies ABG - See Below. 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 I m ag e Ca rd io N et w Case courtesy of Assoc Prof Frank Gaillard, <a href="https://radiopaedia.org/">Radiopaedia.org</a>. From the case <a href="https://radiopaedia.org/cases/15823">rID: 15823</a> 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 - Supplemental oxygen to target 88-92% given COPD - Consider cervical spine fracture & immobilise 10 - Pain management - Consider reversal of anticoagulation Diagnosis Consider - Recognition of subdural haematoma on CT 5 - Acts upon report of cervical spine fracture Investigations Consider - Request for CT Brain and Plain film or CT C-Spine - Bloods (FBC, U&E, ABG/Serum Lactate, CRP) 10 - Request for group and hold - Requests ECG as part of collapse work up Disposition - Need for urgent neurosurgical intervention, 10 orthopaedic input and ICU level care Geriatric Trauma - Team Assessment Non-Technical Skills 50 Points Marks Marks Criteria Available Awarded Team Work Consider - Demonstrating leadership. - Exchanging information. 20 - Regaining situational awareness if team loses focus - Delegating Roles/tasks - Supporting Team Task Management Consider - Planning & preparing - Prioritising 10 - Providing & maintaining standards - Identifying & utilising resources Situation Awareness Consider - Gathering information 10 - Recognising & understanding task fixation - Anticipating Decision Making Consider - Identifying options - Balancing risks & selecting options 10 - Re-evaluating
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