7/27/2019 x ray spine

1/12

Johnny Blade; 27 4/5/1983

Learner Stimulus #6

C-spine x-ray

1

7/27/2019 x ray spine

2/12

Johnny Blade; 27 4/5/1983

Learner Stimulus #7

Pelvis x-ray

2

7/27/2019 x ray spine

3/12

Johnny Blade; 27 4/5/1983

Learner Stimulus #8

Right knee x-ray

3

7/27/2019 x ray spine

4/12

Johnny Blade; 27 4/5/1983

4

7/27/2019 x ray spine

5/12

Johnny Blade; 27 4/5/1983

Learner Stimulus #9

Abdominal Ultrasound/FAST exam

5

7/27/2019 x ray spine

6/12

Johnny Blade; 27 4/5/1983

Learner Stimulus #10

Lactate: 15.5 mEq/L

6

7/27/2019 x ray spine

7/12

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 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

7

7/27/2019 x ray spine

8/12

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 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

8

7/27/2019 x ray spine

9/12

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 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

9

7/27/2019 x ray spine

10/12

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. 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.

10

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

7/27/2019 x ray spine

11/12

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 orotrachealintubation.

Charles Gomersall 2010. http://www.aic.cuhk.edu.hk/web8/trauma%20basics.htm

11

http://www.aic.cuhk.edu.hk/web8/trauma%20basics.htmhttp://www.aic.cuhk.edu.hk/web8/trauma%20basics.htm

7/27/2019 x ray spine

12/12

Johnny Blade; 27 4/5/1983

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

12

http://www.sonoguide.com/FAST.htmlhttp://www.sonoguide.com/FAST.htmlhttp://www.sonoguide.com/FAST.html