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  • 1. Intake, Exposure, Anterior Secondary, IV Access, and Pain Medication
  • 2. Saber Removal and Evaluation of Lacerations
  • 3. Posterior Secondary Exam
  • 4. Completion of Secondary Exam; Right Femur and Right Knee X-Rays; FAST Exam; and Arterial Pressure Index
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Trauma Resuscitation Demonstration in a Stable Patient with a Minor Perforating Wound

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Priya Prakash, MD
UChicago Medicine

Transcription

CHAPTER 1

Okay, so he is 17. He's in the ROTC program, and they were practicing some kind of maneuver with the swords. He dropped it, and he's got a penetrating injury to like the - medial part of the right knee, and then - and there's like an entrance, and then it's got - a couple centimeters below it is an exit So it's still in, we just have it stabilized, has good CMS, he's been holding it kind of still here to keep leverage off it because it's kind of a long saber. Can you tell me your name? Okay, airway's intact. On Will's count, we're going to move on three. Ready? One, two, three. Okay. Can you bring the bed up a little bit? Ouch. All right, guys. I'm going to listen to you. So we're going to expose the patient, we're going to get him on the monitors, we'll establish two large bore IVs, and we'll get a manual blood pressure. Take a deep breath for me. Can I have scissors, please? Take a deep breath. Yes. All right, lung sounds are clear bilaterally. Do you have any allergies? No. Do you have any other medical problems? No. Ah! Sorry bud. Nope. How much do you weigh? We're going to leave that, right? I'm not too sure, maybe 170. 170 lbs. How tall are you? 6' 3". 6' 3". Do you have any allergies? No. 120/82. 120/82. Okay. We'll send a full set of trauma labs once we get IV access in. All right, thumb pulses are intact. Left DP's intact. Right and left DP intact. Pardon me? When did you last eat something? Lunch time, around noon-ish. Can someone grab some warm blankets? All right, can you wiggle your toes for me? Okay, good. Do you know where you are? Pardon me? Do you know where you are? Yes. Okay. DCS of 15. Can we get 50 of fentanyl, please? We'll get some blankets. Big poke, stay still. If you want, there's a pillow behind your head. All right, so I'd say… No allergies, no medical problems, last meal was lunch. There's an 18 gauge in the left hand. After we establish our IV access and we give some pain medication, we're going to attempt to gently remove the sword so that we can turn safely. Okay. Is it sharp on both sides? No. Helen, you can continue with the rest of your secondary anteriorly. Do you have any pain in your head, here? Nope. All right, any pain in your chest? No chest wall tenderness. Any pain in your belly? 50 fentanyl is in. Can you relax a little bit? Pardon me? Relax a little bit. All right, abdomen is soft, non-tender.

CHAPTER 2

All right buddy, so this looks like it just went through the skin. Okay, it's probably away from any major blood vessels, so that's why we're going to try to remove this so that we can turn you and look at your back safely, okay? Pelvis is intact. We just gave you some IV pain medication. Ah! Okay. All right. All right, we're going to slowly pull. Do we have any gauze here? You're doing great, almost done, okay? Perfect, it's all out, okay? All right, so it has a laceration to the right thigh - right medial thigh. He's got a 1-cm lac and one right below, another 1-cm lac. Any hard signs of vascular injury? No. He's got good fem pulses and good PT pulses. Okay. No expanding hematoma, no pulsatile bleeding, distal pulses, no leg ischemia, okay? And then do you feel a thrill? And no thrill. Okay.

CHAPTER 3

So we're going to get ready to turn to his left side. Okay. The sword is intact. We're going to do all the work, okay? All right, on Will's count. I'm going to touch on your back, you just say "yes" or "no" if it hurts, okay? Don't move your neck. On Will's count, we'll turn to the patient's left. Good, ready - one, two three. All right, tuck all of the clothes underneath him Any pain here? Here? Here? Here? Here? We can get this out. No step-offs, no C, T, or L spine tenderness. All right, I'm going to lift this up. We'll look at the right axilla. Right axilla is intact. All right, we'll look at the right perineum. Go ahead and lift this up here. All right, right perineum is intact. We will defer our rectal. Okay, on Will's count we'll move back supine. Ready? One, two, three. We'll do our trauma shuffle. We're just going to go the other way now. Do you know when your last tetanus shot was? I'm not sure. Was that tetanus shot you just asked? Unsure. Okay. Ready? On Will's count we'll move to the patient's right. One, two, three. I'm going to lift this arm up. Okay, we'll get all the clothes out from underneath him. All right, left axilla is intact. Lift this leg up. All right, left groin's intact. Okay. All right, we'll turn back supine on Will's count. Ready? One, two, three. Okay, and let's just - everyone stay where they are, we'll just make sure he's appropriately positioned on the bed. We can go down a little. We could move him down a little bit. Okay. We can go down like… And maybe to patient right a little bit. Yeah, okay. He's tall. Ready? One, two. Okay, all right. Is that more comfortable? Great.

CHAPTER 4

Helen, we'll have you finish your secondary exam with a good motor and sensory exam of all extremities. All right, good. Do you feel me touching you? Pardon me? Do you feel me touching you? Over here? Yeah, we'll get a right femur and a right knee x-ray. All right, does it feel the same? Yeah. All right, sensation intact in bilateral upper extremities Do you feel me touching you here? Yes. All right, what about here? Feel the same on both sides? All right, sensation's intact in bilateral lower extremities Can you push down on my hands? Gas pedal? Okay. Go up. Good. We'll do a FAST exam as well. Any pain in this leg when I press? No. Nothing here? No. Can you bend this knee for me? Bend this knee. Just relax. Bend the knee. Okay, good. Any pain back there? Nope. Can you bend this one a little bit? Any pain back here? No. Here? Right there, yeah. Right there? Yeah. All right, it's tender to palpation to the medial right thigh. Has good range of motion. And Helen, we'll have you do an API after you're done with your secondary. Do you take any medicines? Nope. All right, have you had any surgeries in the past? No. All right, any recreational - drugs like cocaine, heroin, anything like that? Nope. Do you smoke? No. Okay. I'm going to draw a little blood on your arm here, okay? Okay. X-ray. You want to help me? You want to help me? Femur? Yeah, we'll just get a femur. All right, can you tell me what happened? Me and my friend were practicing our saber team routine for the upcoming military ball. Okay. And we were supposed to toss the swords across to each other and catch them. I fumbled on the catch and it went into my leg. Yeah, we're just confirming he didn't have any blunt trauma or concern for any chest problems. Okay, but you didn't fall, or hit your head, or anything else? No. Just the sword? Yeah. Okay. No blunt trauma. Okay. So no chest x-ray. All right bud, we're going to put this under your leg, okay? X-ray. I think you're okay. Right? Because you got the knee. We don't need all the way up there. Okay. Yeah, no, we're good. Thank you. Yeah, it's just that there. So I'm trying to see if you can angle it a little bit. So like 119? So compared to the uninjured… So now do the uninjured extremity. I don't like using that. I don't think it's accurate, and I think that's why we've been getting really inaccurate ABIs and getting CTAs on everybody Okay. Because this - right? This wound is fairly superficial so very unlikely that he has a distal SFA or proximal popliteal artery injury. So this was what side, 1… This was 118. 118/121 anyway is 0.975. We're just going to finish the API, and as long as that's above 0.9, no. I think it was 138. Try it again? Do this side again. So 138 on that side? Okay, so we'll redo this side. Ready? Mm hmm. Keep going. Okay, can you go a little bit more, yeah. So 132. Yeah, so we're good.