Brought to you by: Maninder Singh and Priya Ghelani
Trauma Rounds (Dr. Walker et al):
-Always do a vascular exam on your trauma notifications (ex GSW to leg- check for peripheral pulses) to not miss occult injuries
-Hard signs of vascular injury in penetrating trauma: absent pulses, bruit/thrill, active/pulsatile hemorrhage, signs of limb ischemia/compartment syndrome (the 6 Ps), pulsatile/expanding hematoma). All of these patients should skip CT and go straight to OR.
-FAST exam is indicated in blunt trauma, not penetrating trauma. Unstable patients should go to the OR and stable patients go to CT. That being said, the lung and cardiac views can still change management by detecting a PTX or large pericardial effusion.
-Lethal triad in trauma: Coagulation, Acidosis and Hypothermia (hence the massive transfusion protocol).
-For further reading on MTP, check out our post: https://emrounds.org/massive-transfusion-protocol-3/
-Improving outcomes w/ ED thoractomy: Intubate, OGT (helps distinguish esophagus from aorta when cross clamping), large bore IVs or bilateral femoral cordis (for Belmont and MTP), R sided chest tube (to determine if need conversion to clamshell thoracotomy), R subclavian cordis (once you cross clamp the aorta, your femoral cordis will not allow for any blood to travel to upper body)
-For further reading on ED thoractotomy: https://emrounds.org/thoracotomy-2/
-In regards to TXA, the NNT was 67 with a 1.5% decrease in all-cause mortality (CRASH2 attached), Followup study (MATTERs), 24->18% decrease in mortality.
-For further reading on TXA: http://www.emdocs.net/txa-use-trauma-update/
Abscesses/I&D (Dr. Ciorciari):
-US can help confirm whether there is a drainable collection. However, TC’s rule is “If it hurts, make a cut”
-Max dose of lidocaine: 4-5mg/kg
-Max dose of lidocaine with epinephrine: 7 mg/kg
-When anesthesizing the area, needle should reach the bottom of the dermis (will have no effect if you stay in the subq). Use #11 blade. Incision should be 2/3 of the area of the fluctuance to prevent treatment failure. Probe the abscess with the curved hemostats (kellys) to break up loculations
-Controversial practices without much evidence (patient-specific decisions): packing, wound cultures. Involve the patient in your decisions.
-Indications for antibiotics if multiple/recurrent abscesses, overlying cellulitis, systemic symptoms (fever), immunosuppression/co-existing conditions, extremes of age, lack of response to I&D alone. For overlying cellulitis when MRSA is not suspected, keflex should be sufficient (cover strep).
Hand Exam (Dr. Leibling):
-Flexor tendons are more complicated than the extensor tendons (two flexors but only one set of extensors for each digit).
-Extensor tendon injuries can be repaired in ED if both sides of tendon visualized in laceration but flexor tendon injuries should not be repaired in ED
-Exam: document the wound location/size, sensory/motor exam, check both radial and ulnar pulses
-Sensory exam: check for deficits in medial, ulnar or radial nerve distribution and two point discrimination test (can open up a paperclip)
-Motor exam: Median (OK sign, touch tip of thumb to pinky), Ulnar (spread fingers apart), Radial (dorsiflex fist against resistance)- https://www.youtube.com/watch?v=jYvBlK3KZWc
-Amputations: place amputated part in moist gauze, into a plastic bag and then place bag over ice