Nick Mancini 11/20/17

S street

C chest -CXR

A abd - FAST

L long bone - xray

P pelvis xray

Reconstituted blood - 1:1:1 ratio

Replace what is being lost

Chest Trauma keep patient in c-collar

Disability/exposure/environment

The patient has a patent airway; he is not pooling his secretions, and his gag reflex is intact. There is a 3
cm stab wound located on the left anterior chest, mid-clavicular line, 3cm below the nipple. Small air
bubbles can be seen at the site. Breath sounds are somewhat decreased on the left side with tracheal
deviation. He has good heart tones, and radial pulses are present but thready. He is moving all 4
extremities spontaneously, and moaning. Vitals show a HR = 120, BP = 80/60, and RR = 28. Pulse ox is
unavailable at this time. He has been placed on 100% O2, cardiac monitor shows sinus tachycardia, and
IV access is being obtained with 2 large bore catheters.

2) What procedure should be done next? When during the course of the physical exam should it have
been done? How would you have performed this procedure?

Needle decompression prior to chest tube placement

After the above procedure is performed, the patients status remains unchanged. BP is still 80/60 and HR
= 120.

3) What is Becks triad? What would it indicate? How would you treat it?

Becks Triad Tamponade: muffled heart sounds, JVD, Hypotension with narrowed pulse
pressure

Sub-xyphoid approach, use US to guide decompression (also check for pericardial sac)
Nick Mancini 11/20/17

Bowing of right ventricle (left is more muscular) tamponade physiology

After two liters of normal saline, the patient is still tachycardic but blood pressure is now 110/60 and the
patients status seems to be improving. PRBC have been ordered. Radiographs have been obtained with
results pending. Trauma labs have been sent. Secondary survey has been completed with no additional
injury noted. Suddenly the nurse tells you: Doctor, something has gone wrong. The patients blood
pressure has dropped to 80/palp and their heart rate is now 125 bpm.

4) What would you do?

ABCs

5) What therapeutic treatment would you give now? What injuries are you concerned with at this point in
your evaluation?

Probably needs blood

6) What additional tests might you consider?

CT scan?, can we manage in our unit if cannot transfer.

Nick Mancini 11/20/17

You are staffing an Emergency Department when a crying 3-year-old child is brought in by ambulance
with a burn. The mother is with the child. She relates that she had placed some potatoes in a pan of oil on
a gas stove to cook and had gone into the pantry to get some items when the child, unwitnessed, grabbed
the pan spilling hot oil on himself and the stove. The oil on the stove ignited. When the mother rushed
back into the kitchen, the kitchen was filling with black smoke, and the child was coughing, crying and
complaining of right arm pain. EMS arrived to find mother and child outside the smoldering apartment.
The child responded to the mothers questions at the scene and seemed awake and alert. The only
significant past medical history is mild active airway disease which occasionally requires an albuterol
syrup. Obvious redness and blisters are noted on the childs right hand and arm up to his short sleeve
shirt. The child was transported in the mothers arms with 100% O2 by facemask.

1) What should you do next? What piece of equipment in the ED would be useful in a pediatric
resuscitation?

ABCs, estimate height of child (to estimate weight for dosing)

Intubation equipment

The patients airway is clear with only a small amount of carbonaceous soot noted at the nares. Breath
sounds are clear bilateral. Patient has good pulses. With exposure, the child is noted to have blisters and
erythema around the entire arm with the fingers being spared. There are also blisters and erythema on the
entire anterior chest and abdomen. Sensation is still intact on all skin areas. The rest of the exam is
normal. The mother states the child weighs 35 lb.

2) Calculate the body surface of the burn. Which burns are full vs. partial thickness? What local wound
care is necessary? What are the childs fluid requirements? How do you follow hydration status?

1 superficial erthythema, blanching, painful

2a superficial partial thickness initially blisters (fluid filled)

2b deep partial

3 full thickness insensate

Usually more than one degree during a burn.

2b can progress to 3, may need skin grafting.

Need to consider pain control.

Nick Mancini 11/20/17

General Burn Victim

20% coverage need to be concerned about fluid loss

For older/younger patients 10% coverage.

Debride the wound, topical antibiotic, non-adherent dressing

How much fluid do they need?

Giving fluid first half in first 8hrs, second half in next 16 hours.

5) How is pulse oximeter affected by CO? What are the usual symptoms of poisoning? What is the
specific treatment? At what level is more aggressive treatment considered?

It DOES NOT

ABG or VBG Arterial gives more info but is harder. Look at carboxyhemoglobin.

Treat with O2: on 100% rebreather about 40 minutes. 4 hours in ambient air.

Higher exposures neuro complaints can have persistent symptoms

A 65-year-old white female comes into the ED complaining of severe headache with nausea and
vomiting. The husband states that his wife has been vomiting violently for the past 2 hours. you see the
patient and indeed she is retching into an emesis pan.

1) In light of the above what would be your differential diagnosis? (Remember to consider life
threats)

Stroke, meningitis, aneurysm, migraine, tension, cluster, trauma, recent LP.

Nick Mancini 11/20/17

A 65-year-old white female comes into the ED complaining of severe headache with nausea and
vomiting. The husband states that his wife has been vomiting violently for the past 2 hours. You see
the patient and indeed she is retching into an emesis pan.

1) In light of the above what would be your differential diagnosis? (Remember to consider life
threats)
2) What would be your initial treatment of this patient?

The patients retching begins to lessen and she tells you that her headache started to come on in the car
after returning from the theater. She tells you that she has never had this type of headache before and her
vision is significantly affected.

3) What are the other parts of the history you would like to address?

The husband states that she has had mild headaches in the past attributed to eyestrain. Patient stated that
she saw halos in her vision after coming out of the theater. The patient is on one hypertensive medication
and takes a multivitamin a day. She has had no history of migraine headaches and wears glasses. Her
headache was gradual in onset. Pain is worse over the right eye. Patients vital signs are TEMP 98.5 F,
RR 20, HR 100, BP 140/75 pulse Ox 99% on RA.

Check pressures: acute-angle glaucoma.

Less likely: meningitis, increased ICP

5) What specifics on the physical exam would you want to know now?

6) What would the slit lamb exam show? What other examination tool would you

consider?

7) What lab data would you want to get on this patient at this time?

8) What else do you need to do?

Start acetazolamide, call ophthalmologist

9) What medications would you give in the ED to initially manage this patient?
Nick Mancini 11/20/17

Treatment was initiated while locating an ophthalmologist and her symptoms subsided within 2

hours of treatment. Patient was grateful

A 52-year-old male comes to the Emergency Department complaining of a headache. He states he has had
some mild flu-like symptoms over the last few days, and this afternoon he developed a headache like I
never had before. The headache is severe, bilateral, pounding, and came on suddenly about 12 hours ago.
The patient also noted some mild neck pain today and photophobia. The patient relates symptoms of
myalgia, fatigue and mild nausea the last couple of days, adding that several colleagues at work have had
similar symptoms the last 2 weeks.

Past Medical History includes some mild hypertension, but never requiring medication. He has never had
a history of migraines, stating he only rarely gets headaches. He is taking no medications and has no
allergies. Social history reveals the patient to be a 40-pack-a-year smoker; he works in the concrete
industry. His wife brought the patient to the Emergency Department.

1) What is the differential diagnosis in this patient with headache?

Physical exam reveals a strong-appearing, age-appropriate male in no distress. He is sitting on

the bed talking to his wife. Vitals show T = 100.4, heart rate = 97, respiratory rate = 18, and

blood pressure = 165/95. HEENT shows pupils briskly reactive and symmetric, and he

complains of photophobia only when prompted. Oropharynx is moist without significant

findings. Fundoscopic exam is clouded by cataracts bilateral. Face is symmetric and has no

tenderness. Neck exam shows no nuchal adenopathy, and his neck is supple although he
Nick Mancini 11/20/17

complains of some discomfort when his neck is fully flexed. He has no frank meningismus.

Chest and heart exam is unremarkable as is his abdominal exam. Neuro exam shows normal

symmetric strength and preserved sensation to light touch throughout. His muscle stretch

reflexes are normal. He has a slight pronator drift on the right. He has negative Romberg test

and normal gait.

Diff Dx

Cushings: increased ICP, bradycardia, irregular respirations,

Further testing: CT scan of head (first 6 hours show bleed ~ 100%)

The patient requests something for pain and is given 1 gram of oral Tylenol.

5) Should this patient have any further medication prior to the CT scan?

6) What are the signs and symptoms of meningitis in adults?

If RBCs LP may be traumatic Tap

Rules out bacterial Meningitis, does not rule out viral.

Reassurance & Expectations