patient name; age · web viewutilize cxr, pelvis xr, & lateral c-spine xr to delineate the...
TRANSCRIPT
Johnny Blade; 27 4/5/1983
Author: Anthony J. Medak, MD University of California, San Diego
Reviewer: Danielle Hart, MD
Case Title: Multi-System Trauma
Target Audience: EM residents
Primary Learning Objectives 1. Develop an algorithmic approach to the management of a critically ill multisystem trauma patient2. Demonstrate an approach to management of hypotension/shock in the trauma patient3. Recognize and utilize the role of bedside ultrasonography in the management of trauma patients
Secondary Learning Objectives1. Develop an approach to airway management in a patient with altered sensorium and facial trauma.2. Quickly recognize and treat a knee dislocation with neurovascular compromise, and understand the potential for associated injuries. 3. Utilize CXR, Pelvis XR, & lateral C-spine XR to delineate the etiology of shock in a multisystem trauma patient4. Develop an understanding of which trauma patients require emergent operative intervention versus further diagnostics, such as CT scan.5. Demonstrate the ability to maintain communication with family (updates on patient’s condition), even under the most grave of circumstances.
Critical actions checklist 1. Immediate intubation while maintaining C-spine immobilization 2. Perform a basic neurologic exam (pupils, corneal reflexes, withdrawal to pain) prior to giving paralytics3. Aggressive IVF and blood product administration for hypotension/shock4. Perform a FAST exam and recognize intraperitoneal hemorrhage5. Recognize and immediately reduce R knee dislocation, verify pulses are present after reduction6. Obtain CXR, Pelvis XR, & C-spine XR in a hemodynamically unstable multi-trauma patient7. Call the Trauma surgeon for immediate operative intervention. NO CT IMAGING!8. Explain patient’s condition to the family in the waiting room
Environment (if using as a simulation case)A. Lab Set Up – Urban Level 1 Trauma Center, ED trauma bayB. Manikin Set Up
1. High Fidelity Simulator2. Moulage
a. Bloody secretions in oropharynx (if possible)b. Dental trauma (if possible)
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Johnny Blade; 27 4/5/1983
c. Large abrasions to R face / cheekd. R periorbital ecchymosis & swellinge. Ecchymosis & erythema to R flank and RUQf. R knee deformity & dusky R foot (if possible)g. Wig appropriate for 27 y/o M
3. Lines: 2 PIVs – 20,18,16,14g available, central line trauma cath kit or cordis available (triple lumen catheter can also be available)
4. IVFs / Blood Products: NS, LR, PRBCs, FFP, platelets5. Drugs (this list includes medications the participants may ask for, even if
incorrect) a. Basic code cart medications assumedb. Pressors (i.e. phenylephrine, epinephrine, norepinephrine, dopamine)c. RSI, sedation & analgesia (i.e. etomidate, succinylcholine,
vecuronium, rocuronium, versed, fentanyl, morphine, dilaudid)6. Airway Equipment
a. Basic airway equipment availableb. ILMA or other backup device available
C. Props 1. Backboard2. Cervical Collar3. Level 1 rapid fluid infuser or equivalent device
D. Distractors – none
Actors (optional)1. Roles – patient, nurse, EMS providers, Trauma Surgeon2. Who may play them – oral board examiner or actors for simulation as below.
a. Patient: High Fidelity Simulator or Standardized Patientb. Nurse: Best if this role is played by a nurse who works clinically in the ED or
ICU, but can be played by resident / attending physicians, nurse educators, or very well trained actors
c. EMS Providers: Can be played by actors, residents, medical students, or others
d. Trauma Surgeon: Should be played by senior resident or attending physician3. Action Role – EMS: give additional history. RN: carry out orders. Surgeon: take
patient to OR emergently. Further details below for simulation cases. a. Patient: Unresponsiveb. Nurse: Helpful, does not mislead participants, does what participants ask
him/her to do, clarifies all doses of medications and rates of infusions. Mediocre ED nurse.
c. EMS Providers: Gives basic report upon arrival. Answers additional questions when asked.
d. Trauma Surgeon: For novice learners, trauma surgeon asks if they think the patient needs a CT first, when they answer ‘no’, he takes the patient to the OR. Option for advanced learners - trauma surgeon can be cantankerous, doesn’t want to take the patient to OR immediately, requesting or demanding CT scan of the patient first.
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Johnny Blade; 27 4/5/1983
For Examiner Only
Author: Anthony J. Medak, MD Reviewer:
Case Title: Multi-System Trauma
CASE SUMMARY
CORE CONTENT AREA
Trauma, Orthopedics
SYNOPSIS OF CASEThis is a trauma patient who presents after a high velocity motorcycle crash. He is critically ill upon presentation and needs several immediate procedures for stabilization. Including intubation, IVF resuscitation and blood products, as well as reduction of a knee dislocation with neurovascular compromise. There are no diagnostic challenges in the case, if the candidate follows basic ATLS guidelines.
SYNOPSIS OF HISTORYThe patient was part of a multiple car pile up on a nearby highway. Other victims are at various local Trauma Centers. He was wearing a helmet, and broadsided a vehicle as it made a rapid lane change to avoid another vehicle. The patient was ejected from his motorcycle, landing on the shoulder of the road in some brush. He was minimally responsive on scene, but EMS was unable to obtain a definitive airway. One victim was pronounced dead at the scene. No family or PMH are available during the initial stages of the case.
SYNOPSIS OF PHYSICALPhysical exam findings are not subtle in this case. Dental trauma and blood in airway, as well as decreased level of consciousness require intubation. Hemotympanum is noted on the left. He is very tachycardic, pulses are thready. Abdomen is soft, but a large ecchymosis over the right flank is evident. Right knee is grossly deformed and is obviously dislocated. The right DP and PT pulses are not palpable. The foot is cool with delayed cap refill.
CRITICAL ACTIONS1. Immediate intubation while maintaining C-spine immobilization 2. Perform a basic neurologic exam (pupils, corneal reflexes, withdrawal to pain) prior to giving paralytics3. Aggressive IVF and blood product administration for hypotension/shock4. Perform a FAST exam and recognize intraperitoneal hemorrhage5. Recognize and immediately reduce R knee dislocation, verify pulses are present after Reduction6. Obtain CXR, Pelvis XR, & C-spine XR in hemodynamically unstable multi-trauma patient7. Call the Trauma surgeon for immediate OR resuscitation. NO CT IMAGING!8. Explain patient’s condition to the family in the waiting room
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Johnny Blade; 27 4/5/1983
For Examiner Only
CRITICAL ACTIONSSCENARIO BRANCH POINTS/ PLAY OF CASE GUIDELINES
1. Critical Action: Immediate intubation while maintaining C-spine immobilization
This critical action is met by the candidate's quick recognition that the patient is obtunded and has blood in his airway. The examiner may use their discretion and make the intubation difficult, easy, etc. based on how the candidate is performing thus far.
Cueing Guideline: A medical student may ask “Should I hold his neck while you intubate?”
2. Critical Action: Perform a basic neurologic exam prior to paralytics
This critical action is met by the candidate's performing a rudimentary neurologic exam prior to paralyzing him for RSI. This is accomplished by assessing the pupils and assessing his response to painful stimuli, and can also include checking for corneal reflexes, gag, etc.
Cueing Guideline: A nurse may ask: “What’s his GCS?” or “What are his pupils like?” just prior to intubation
3. Critical Action: Aggressive IVF and blood product administration for hypotension/shock
This critical action is met by the candidate's rapid recognition of hypotension due to hypovolemic shock. Therapy should begin with isotonic IVF, then when minimal improvement is noted, should progress to blood products.
Cueing Guideline: The nurse may ask: “Doctor, he’s not really getting much better with these fluids, do you want to give anything else?” IF the participant still does not ask for blood, then the blood bank tech who is in the ED may ask “Doctor, will you be needing any blood?”
4. Critical Action: Perform a FAST exam and recognize peritoneal hemorrhage
This critical action is met by the candidate's performing a rapid FAST exam with the ED U/S machine. In addition, the candidate must correctly interpret the positive U/S results.
Cueing Guideline: The nurse may state: “I wonder why he’s not improving. Do you think he’s still losing blood somewhere?” IF the participant still does not ask for an U/S, a medical student may ask: “How can we figure out where he’s bleeding?” IF the participant still does not ask for an U/S, the nurse may ask: “Will you be needing the ultrasound during this case?”
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Johnny Blade; 27 4/5/1983
For Examiner Only CRITICAL ACTIONS (continued)
5. Critical Action: Recognize and immediately reduce R knee dislocation, verify pulses are present after reduction
This critical action is met by the candidate's recognition that the knee is grossly deformed (only if candidate does an extremity exam) and that the right foot perfusion is compromised. They should immediately give some analgesia and reduce the knee, followed by reassessing the pulses and perfusion in the right foot. The leg should then be immobilized.
Cueing Guideline: The nurse may ask: “What do you think about his leg, is it broken?”
6. Critical Action: Obtain CXR, Pelvis XR & C-spine XR in hemodynamically unstable multi-trauma patient
This critical action is met by ordering a CXR, Pelvis XR, & lateral C-spine XR.
Cueing Guideline: The nurse may state: “Radiology would like to know if you want any plain films on this patient.”
7. Critical Action: Call the Trauma surgeon for immediate OR resuscitation
This critical action is met by the candidate's recognition and understanding of the U/S results. With this information, he/she must now contact the Trauma Surgeon and inform them of the need for an OR resuscitation. The candidate MUST NOT allow the patient to go to the CT scanner.
Cueing Guideline: If the candidate is ordering CT imaging, the CT tech on the phone will ask: “Is your patient stable enough to come to the CT scanner?”
8. Critical Action: Explain patient’s condition to family in the waiting room
This critical action is met by the candidate's asking if family has yet arrived. When they are present, the candidate should take the time to explain the patient’s condition and answer their questions. The candidate should be empathetic and respectful in his/her demeanor.
Cueing Guideline: If the candidate does not ask about family, the Social Worker will say:“Doctor, this patient’s family is now in the waiting room. They are very distraught and would like to speak with you.”
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Johnny Blade; 27 4/5/1983
For Examiner Only
PLAY OF CASE GUIDELINES
This is a critically ill motorcycle crash victim. He was a helmeted rider that struck another car at freeway speeds. He was ejected from his motorcycle and found 20 feet from his bike in some scrub brush along the freeway shoulder. Another driver involved in the crash was pronounced dead at the scene. EMS reports getting 2 large IVs but were unable to intubate. He was mildly hypotensive en route (SBP in the low 90-100 range). He has been unresponsive throughout transport. No known PMH. Police are calling to notify family at this time.
The candidate needs to perform multiple life & limb saving interventions immediately in the ED, including intubation, administering IVF and blood products, and reducing the knee dislocation (and verify the improved perfusion of the foot after reduction). After initial stabilization, the candidate should perform a FAST exam and recognize hemoperitoneum. Xrays of the C-spine, chest, pelvis, and right knee should all be obtained.
The candidate should frequently reassess indices of perfusion including urine output, as well as frequent BP monitoring (noninvasive or via arterial line). The candidate SHOULD NOT allow the Trauma surgeon, nurses, etc to convince him/her to send the patient to CT. If so, the patient will code in the scanner and not respond to any resuscitative efforts.
SCORING GUIDELINES
1. Score up if they ask EMS personnel to stay around, and obtain a detailed history from the EMS providers after the primary survey is complete
2. Score up if they intubate expeditiously; score down if they continue on to the secondary survey before intubating
3. Score up if they vocalize that they will maintain C-spine immobilization during intubation; score down if they do not
4. Score up if they use head injury specific medications for / with RSI (lidocaine, fentanyl, etc.)5. Score up if they recognize clinical findings of ICH (obtundation, facial trauma and
hemotympanum)6. Score up if they reduce the knee dislocation and verbalize that angiography will be needed
once he is stable
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Johnny Blade; 27 4/5/1983
For Examiner Only
HISTORY
Onset of Symptoms: Patient is a 27-year-old male brought in by Paramedics. He was a motorcycle rider involved in a multi-vehicle crash on a nearby highway. Patient broadsided a vehicle that made a sudden lane change in front of him. He struck the car on the driver’s side, then was ejected from his bike. He was found ~20 feet away, on the freeway shoulder, in some scrub brush. He has been unresponsive. EMS was unable to intubate, but did get good IV access. He has been hypotensive (SBP range 90-100s) during transport. Police
have contacted family and they are en route to hospital. Another driver in the crash was pronounced dead at the scene.
Background Info: Patient was found on the shoulder of a nearby highway, ejected 20 feet from his motorcycle after striking a car involved in a multi-vehicle crash.
Chief Complaint: Unable to provide due to altered level of consciousness (LOC)
Past Medical Hx: UnknownPast Surgical Hx: Unknown
Habits: Smoking: UnknownETOH: UnknownDrugs: Unknown
Family Medical Hx: Unknown
Social Hx: Unknown
ROS: Unable to obtain due to altered LOC
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Johnny Blade; 27 4/5/1983
For Examiner Only
PHYSICAL EXAM
Patient Name: Johnny Blade Age & Sex: 27 yr old man
General Appearance: Ill appearing man, bleeding from the face, in full spine precautions
Vital Signs: BP 95/57 HR 132 Resp bagged T 99.0F O2 sat 96% with BVM FSBG 108 mg/dL
Primary Survey:-Airway: blood in oropharynx, dental trauma evident, no gag → candidate should proceed to intubate-Breathing: (after intubation) good breath sounds bilaterally-Circulation: thready radial and femoral pulses, carotid pulses are normal. Two 16 gauge IVs placed by EMS are working well. Secondary Survey: Head: large (6 x 8 cm) abrasions to right face/cheek.
Eyes: pupils 4 to 3 mm but sluggish, corneal reflexes present. Right periorbital swelling and
ecchymoses
Ears: hemotympanum on left
Mouth: blood in mouth, dental fxs of inferior central incisors
Neck: in cervical collar, no crepitus or gross deformities/masses/hematomas
Skin: Diaphoretic; capillary refill greater than 3 seconds; slightly pale
Chest: clear lung sounds to auscultation bilaterally
Heart: tachycardic, regular, no murmurs
Abdomen: Soft; non-distended, and no rigidity; bowel sounds are decreased; no scars; no
masses; 10 x 8 cm ecchymosis and erythema to right flank and RUQ
Genito-Urinary: nl penis and scrotum
Extremities: nl except for right knee with obvious deformity (dislocated). Right foot is cool and
neither dorsalis pedis nor posterior tibialis pulses are palpable.
Rectal: no gross blood, nl tone
Pelvis: stable
Back: Normal
Neurological: unresponsive with eyes closed; pupils 4 to 3 mm but sluggish, +corneal reflexes;
no vocalizations whatsoever; withdraws to painful stimuli
Other exam findings: (if specifically asked by candidate) Bedside Emergency Department U/S (provide stimulus sheet #9) reveals free fluid in Morrison’s Pouch, no PTX, and no pericardial effusion.
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Johnny Blade; 27 4/5/1983
For Examiner Only
STIMULUS INVENTORY
#1 Emergency Admitting Form
#2 CBC
#3 BMP
#4 Urinalysis
#5 Chest xray
#6 C-spine xray
#7 Pelvic xray
#8 R knee xray (post reduction)
#9 Abdominal Ultrasound/FAST exam
#10 Lactate
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Johnny Blade; 27 4/5/1983
For Examiner Only
LAB DATA & IMAGING RESULTS
Stimulus #2 Stimulus #5Complete Blood Count (CBC) CXR: nlWBC 15.2/mm3
Hgb 13g/dL Stimulus #6Hct 40% C-spine xray: nlPlatelets 420/mm3
Differential Stimulus #7Segs 70% Pelvis xray: nlBands 1%Lymphs 24% Stimulus #8Monos 4% Right knee xray (post-reduction): Eos 1% tibial spine fx
Stimulus #3 Stimulus #9Basic Metabolic Profile (BMP) Abdominal U/S: + free fluid in Morrison’s Na+ 143 mEq/L pouchK+ 4.2 mEq/LHCO3 16 mEq/L Stimulus #10Cl- 109 mEq/L Lactate: 15.5 mEq/LGlucose 115 mg/dLBUN 16 mg/dL Verbal Reports
Creatinine 0.9 mg/dL PT / PTT / INR = INR 1.0Blood alcohol : NMA
All other tests are normal and/or unavailable
Stimulus #4 Urinalysis (U/A)Color yellow, clearSp gravity 1.015Glucose negProtein negKetone negLeuk. Est. negNitrite negWBC 0-1/HPFRBC 10-15/HPF
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Johnny Blade; 27 4/5/1983
Learner Stimulus #1
ABEM General HospitalEmergency Admitting Form
Name: Johnny Blade
Age: 27 years
Sex: Male
Method of Transportation: EMS
Person giving information: EMS personnel
Presenting complaint: Multi-vehicle freeway crash
Background: Patient was found on the shoulder of the 5 freeway, ejected 20 feet from his
motorcycle after striking a car involved in a multi-vehicle crash.
Triage or Initial Vital Signs BP: 95/57 mmHg
P: 132/minute
R: being bagged
Pulse Ox: 96%
T: 99.0 rectally
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Johnny Blade; 27 4/5/1983
Learner Stimulus #2
Complete Blood Count (CBC) WBC 15.2/mm3
Hgb 13g/dLHct 40%Platelets 420/mm3
DifferentialSegs 70%Bands 1%Lymphs 24%Monos 4%
Eos 1%
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Johnny Blade; 27 4/5/1983
Learner Stimulus #3
Basic Metabolic Profile (BMP) Na+ 143 mEq/LK+ 4.2 mEq/LHCO3 16 mEq/LCl- 109 mEq/LGlucose 115 mg/dLBUN 16 mg/dLCreatinine 0.9 mg/dL
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Johnny Blade; 27 4/5/1983
Learner Stimulus #4
Urinalysis (U/A)Color yellow, clearSp gravity 1.015Glucose negProtein negKetone negLeuk. Est. negNitrite negWBC 0-1/HPFRBC 10-15/HPF
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Johnny Blade; 27 4/5/1983
Feedback/ Assessment Forms
Multi-System Trauma
Candidate ________________________ Examiner _________________________
Critical Actions:
Critical Action #1: Immediate intubation while maintaining C-spine immobilization Critical Action #2: Perform a basic neurologic exam prior to giving paralytics Critical Action #3: Aggressive IVF and blood product administration for hypotension/shock Critical Action #4: Perform a FAST exam and recognize intraperitoneal hemorrhage Critical Action #5: Recognize and immediately reduce knee dislocation, verify pulses are
present after reduction Critical Action #6: Obtain CXR, Pelvis XR, & C-spine XR in hemodynamically unstable
multi-trauma patient Critical Action #7: Call the Trauma surgeon for immediate OR resuscitation. NO CT
IMAGING! Critical Action #8: Explain patient’s condition to the family in the waiting room
Dangerous Actions: (Performance of one dangerous action results in failure of the case)
Dangerous Action #1: Sending patient with + FAST exam & hemodynamic instability to CT for further imaging
Dangerous Action #2: Failure to recognize that patient’s BP is not responding to IVF alone and requires blood products.
Overall Score:
Pass Fail
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Johnny Blade; 27 4/5/1983
For Examiner
Date: Examiner: Examinee:
Scoring: In accordance with the Standardized Direct Observational Tool (SDOT)
The learner should be scored (based on level of training) for each item above with one of the following:
NI = Needs ImprovementME = Meets ExpectationsAE = Above ExpectationsNA= Not Assessed
Critical Actions NI ME AE NA CategoryImmediate intubation while maintaining C-spine immobilization
PC, MK
Perform a basic neurologic exam prior to giving paralytics
PC, MK
Aggressive IVF and blood product administration for hypovolemic shock
PC, MK, PBL
Perform a FAST exam and recognize intraperitoneal hemorrhage
PC, MK, PBL
Recognize and immediately reduce knee dislocation, verify pulses are present after reduction
PC, MK
Obtain CXR, Pelvis XR & C-spine XR in unstable trauma patient
PC, MK, PBL
Call the Trauma surgeon for immediate OR resuscitation. NO CT IMAGING!
PC, MK, ICS, SBP
Explain patient’s condition to the family in the waiting room
ICS, P
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Johnny Blade; 27 4/5/1983
Category: One or more of the ACGME Core Competencies as defined in the SDOT
PC= Patient CareCompassionate, appropriate, and effective for the treatment of health problems and the promotion of health
MK= Medical KnowledgeResidents are expected to formulate an appropriate differential diagnosis with special attention to life-threatening conditions, demonstrate the ability to utilize available medical resources effectively, and apply this knowledge to clinical decision making
PBL= Practice Based Learning & ImprovementInvolves investigation and evaluation of their own patient care, appraisal and assimilation of scientific evidence, and improvements in patient care
ICS= Interpersonal Communication SkillsResults in effective information exchange and teaming with patients, their families, and other health professionals
P= ProfessionalismManifested through a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population
SBP= Systems Based PracticeManifested by actions that demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value
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Johnny Blade; 27 4/5/1983
Keywords for future searching functions:Blunt TraumaKnee dislocationHemoperitoneumFAST examHemorrhagic shock
References:Charles Gomersall 2010. http://www.aic.cuhk.edu.hk/web8/trauma%20basics.htm
Marx J. et al, editor. Rosen’s Emergency Medicine, Concepts and Clinical Practice, 5th edition. Chapter 4: Shock. Kline JA. Page 42. Mosby, Inc. St. Louis, Missouri, 2002.
Robert Reardon, MD. http://www.sonoguide.com/FAST.html
Rozycki GS, Ballard RB, Feliciano DV, Schmidt JA, Pennington SD.Surgeon-performed ultrasound for the assessment of truncal injuries: lessons learned from 1540 patients. Ann Surg,1998;228:557-67.
Wherrett LJ, Boulanger BR, McLellan BA, Brenneman FD, Rizoli SB, Culhane J, Hamilton P.Hypotension after blunt abdominal trauma: the role of emergent abdominal sonography in surgical triage. J Trauma,1996;41:815-20.
Has this work been previously published?No, this case has not been published. A similar version of this case was used at my home institution (University of California, San Diego) for our Emergency Medicine Residency Mock oral boards program.
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Johnny Blade; 27 4/5/1983
Debriefing Materials:
1.) Intubation in the setting of suspected cervical spine injury:
Manual In-Line Stabilization is used to stabilize the cervical spine while attempting orotracheal intubation.
Charles Gomersall 2010. http://www.aic.cuhk.edu.hk/web8/trauma%20basics.htm
The provider holding C-Spine Immobilization from the head of the bed (after paralytics) may assist the airway operator to improve vocal cord visualization by adding jaw thrust. Griswold, 2011. 2.) Hemorrhagic Shock: Standard treatment for hemorrhagic shock in adults consists of rapidly infusing 2 liters of isotonic crystalloid per ATLS recommendations. If criteria for shock persist
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Johnny Blade; 27 4/5/1983
despite crystalloid infusion, PRBCs should be infused (5-10 ml/kg). Type-specific blood should be used when the clinical scenario permits, but uncrossmatched blood should be immediately used for patients with hypotension and uncontrolled hemorrhage. O-negative blood is used in women of childbearing age and O-positive blood in all others.
Marx J. et al, editor. Rosen’s Emergency Medicine, Concepts and Clinical Practice, 5th edition. Chapter 4: Shock. Kline JA. Page 42. Mosby, Inc. St. Louis, Missouri, 2002.
3.) FAST Exam: “FAST” is an acronym for Focused Assessment with Sonography in Trauma and has become synonymous with beside ultrasound in trauma. The FAST exam, per ATLS protocol, is performed immediately after the primary survey of the ATLS protocol. Ultrasound is the ideal initial imaging modality because it can be performed simultaneously with other resuscitative cares, providing vital information without the time delay caused by radiographs or computed tomography (CT). The concept behind the FAST exam is that many life-threatening injuries cause bleeding. Although ultrasound is not 100% sensitive for identifying all bleeding, it is nearly perfect for recognizing intraperitoneal bleeding in hypotensive patients who need an emergent laparotomy.
Robert Reardon, MD. http://www.sonoguide.com/FAST.html
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