UNHAS SEKOLAH KEDOKTERAN

PRESENTED BY DR PHILIP STOKOE

16 FEBRUARY 2011

TR A U M A IN TH E
EM ER G EN C Y R O O M

TH E CALG ARY CAM BRIG E SCH EM E

Initiating the session
Gathering information
Physical examination
Explanation and planning
Closing the session

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PO M R -Problem oriented M edicalRecord

A. History
Fall
Head injury
Headache
Difficulty in walking
Semi-conscious

Past history

B.

Hypertension Treatment
Diabetes mellitus
Drug addict
Alcohol use
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PO M R -Problem oriented M edicalRecord Contd

C. Exam
D. Differential diagnosis
E. Initial problem related plans

Imaging
Blood Exam
Monitoring Tests
Treatment

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H ISTO RY TAKIN G SEQ U EN CE

Presenting Symptoms (PS)
History of Presenting Illness (HPI)
Past History (PH)
Social History (SH)
Family History (FH)
System Review (SR)

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PRO G RESS N O TES

S: Subjective
O: Objective
A: Assessment
P: Plan
FLOW CHART
Dx : Diagnostic Test

Blood exam
Imaging

Mx: Monitoring Test

Continuous Blood Tests

Second Imaging
Glasgow scale

Rx: Treatment

IV fluids
O2

Ed: Education

Consultation
Patient Advice
Family Advice
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D IFFEREN TIAL D IAG N O SIS FRO M

SYM PTO M S/SIG N S

A. Neurological systems and mental

state
1. Do you get headache?
2. Is your headache very severe and did it
begin very suddenly? Sub-arachnoid
haemorrhage
3. Have you had memory problems or trouble
concentrating
4. Have you had fainting episodes, fits or
blackouts?
5. Do you have trouble seeing or hearing?
6. Are you dizzy?
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D IFFEREN TIAL D IAG N O SIS FRO M

SYM PTO M S/SIG N S Contd
7. Have you had weakness, numbness or
clumsiness in your arms or legs?
8. Have you ever had a stroke or head
injury?
9. Have you had difficulty sleeping?
10.Do you feel sad or depressed, or have
problems with your nerves?
11.Have you ever been sexually or physically
abused?

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D IFFEREN TIAL D IAG N O SIS FRO M

SYM PTO M S/SIG N S Contd

B. Epilepsy

Genetic
Head trauma
Intra cranial tumours
Strokes
Abcess
Alcohol
Drugs
Uraemia

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D IFFEREN TIAL D IAG N O SIS FRO M

SYM PTO M S/SIG N S Contd

C. Unconsciousness

Boggy scalp swelling

Depression cranium
Alcohol breath
Needle marks
Hepatomegaly
Hypertension/hypotension
Diabetic coma sweet breath

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G RAD IN G O F CO M A
1. Alert
2. Drowsy but responds to verbal stimulation
3. Unconscious no response to verbal

stimulation, but withdrawal response to pain

4. Unconscious decorticate responses to pain
(flexion of upper limb and extension of lower
limb)
5. Unconscious decerebrate responses to pain
(hyperextension of both upper and lower
limbs)
6. Unconscious p no response to pain
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G LASG O W CO M A SCALE
Eye opening

Best verbal
responses

Best motor
responses

Patients
response

Score

Spontaneous

To speech

To pain

None

Oriented

Confused

Inappropriate

Incomprehensible

None

Obeying

Localising

08.00

10.0
0

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12.0
0

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SYM PTO M S/SIG N S O F CO M A

Take history if possible
Assess level of consciousness use Glasgow

coma scale but remember its limitations

Look for sings of meningeal irritation
Assess pupils
Assess ocular movements, if necessary using
dolls head manoeuvre
Assess motor responses
Assess respiration
Perform a general physical examination,
including the heart, abdomen and skull
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CRITERIA FO R BRAIN D EATH

Dilated pupils
No corneal response
Vestibular ocular reflex
Motor response to painful stimulus to

glabella
No gag response to tracheal
response
Steroterious breathing
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TH E U N CO N SCIO U S PATIEN T

C CO2 narcosis (respiratory failure:

uncommon)

O Overdose: for example, trangquillisers,

alcohol, salicylates, carbon monoxide,
antidepressants

M- Metabolic: for example, hypoglycaemia,

diabetic ketoacidosis, uraemia,
hypothyroidism, hepatic coma,
hypercalcaemia, adrenal failure

A- Apoplexy: for example, head injury,

cerebrovascular accident (infarction or
haemorrhage),
subdural
or extradural
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G EN ERAL IN SPECTIO N O F TRAUM A PATIEN T

Remember A-B-C:
Airway,
Breathing and
Circulation

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G EN ERAL IN SPECTIO N O F TRAUM A PATIEN TContd

Airway and Breathing:
Look to see if the patient is breathing, as indicated
by chest wall movement. If not, urgent attention is
required, including clearing the airway and
providing ventilation. Note particularly the pattern
of breathing. Cheyne Stokes respiration (which
may indicate diencephalic injury, but is not
specific), irregular ataxic breathing (Biots
breathing, from an advanced brainstem lesion),
and deep rapid respiration (e.g. Kussmaul
breathing, secondary to a metabolic acidosis, as in
diabetes mellitus) are important signs to look for.
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G EN ERAL IN SPECTIO N O F TRAUM A PATIEN TContd

Circulation :
Look for signs of shock, dehydration
and cyanosis. A typical cherry-red
colour occurs rarely in cases of carbon
monoxide poisoning. Take the pulse
rate and blood pressure.

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