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Transcript of x ray spine
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Johnny Blade; 27 4/5/1983
Learner Stimulus #6
C-spine x-ray
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Learner Stimulus #7
Pelvis x-ray
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Learner Stimulus #8
Right knee x-ray
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Learner Stimulus #9
Abdominal Ultrasound/FAST exam
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Learner Stimulus #10
Lactate: 15.5 mEq/L
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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 unstablemulti-trauma patient
Critical Action #7: Call the Trauma surgeon for immediate OR resuscitation. NO CTIMAGING!
Critical Action #8: Explain patients 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 patients BP is not responding to IVF alone
and requires blood products.
Overall Score:
Pass
Fail
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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 oneof the following:
NI = Needs ImprovementME = Meets Expectations
AE = Above ExpectationsNA= Not Assessed
Critical Actions NI ME AE NA CategoryImmediate intubation whilemaintaining C-spine immobilization
PC, MK
Perform a basic neurologic examprior to giving paralytics
PC, MK
Aggressive IVF and blood productadministration for hypovolemicshock
PC, MK, PBL
Perform a FAST exam andrecognize intraperitonealhemorrhage
PC, MK, PBL
Recognize and immediately reduceknee dislocation, verify pulses arepresent after reduction
PC, MK
Obtain CXR, Pelvis XR & C-spineXR in unstable trauma patient
PC, MK, PBL
Call the Trauma surgeon forimmediate OR resuscitation. NO CTIMAGING!
PC, MK, ICS,SBP
Explain patients condition to thefamily in the waiting room
ICS, P
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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 promotionof health
MK= Medical KnowledgeResidents are expected to formulate an appropriate differential diagnosis with special attention tolife-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, andimprovements in patient care
ICS= Interpersonal Communication SkillsResults in effective information exchange and teaming with patients, their families, and other healthprofessionals
P= ProfessionalismManifested through a commitment to carrying out professional responsibilities, adherence to ethicalprinciples, and sensitivity to a diverse patient population
SBP= Systems Based PracticeManifested by actions that demonstrate an awareness of and responsiveness to the larger contextand system of health care and the ability to effectively call on system resources to provide care thatis of optimal value
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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. Rosens 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: lessonslearned 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 abdominalsonography 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 homeinstitution (University of California, San Diego) for our Emergency Medicine Residency Mockoral boards program.
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http://www.aic.cuhk.edu.hk/web8/trauma%20basics.htmhttp://www.sonoguide.com/FAST.htmlhttp://www.sonoguide.com/FAST.htmlhttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=9790345&ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSumhttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=8913209&ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSumhttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=8913209&ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSumhttp://www.aic.cuhk.edu.hk/web8/trauma%20basics.htmhttp://www.sonoguide.com/FAST.htmlhttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=9790345&ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSumhttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=8913209&ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSumhttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=8913209&ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum -
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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 orotrachealintubation.
Charles Gomersall 2010. http://www.aic.cuhk.edu.hk/web8/trauma%20basics.htm
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The provider holding C-Spine Immobilization fromthe head of the bed (afterparalytics) may assist theairway operator to improvevocal cord visualization byadding jaw thrust.Griswold, 2011.2.) Hemorrhagic Shock:Standard treatment forhemorrhagic shock inadults consists of rapidlyinfusing 2 liters of isotoniccrystalloid per ATLSrecommendations. Ifcriteria for shock persist
despite crystalloid infusion,PRBCs should be infused(5-10 ml/kg). Type-specificblood should be usedwhen the clinical scenariopermits, but uncrossmatched blood should be immediately used for patients with hypotensionand uncontrolled hemorrhage. O-negative blood is used in women of childbearing age and O-positive blood in all others.
Marx J. et al, editor. Rosens 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 Traumaand 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 isthe ideal initial imaging modality because it can be performed simultaneously with otherresuscitative cares, providing vital information without the time delay caused by radiographs orcomputed tomography (CT). The concept behind the FAST exam is that many life-threateninginjuries cause bleeding. Although ultrasound is not 100% sensitive for identifying all bleeding, itis nearly perfect for recognizing intraperitoneal bleeding in hypotensive patients who need anemergent laparotomy.
Robert Reardon, MD.http://www.sonoguide.com/FAST.html
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http://www.sonoguide.com/FAST.htmlhttp://www.sonoguide.com/FAST.htmlhttp://www.sonoguide.com/FAST.html