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Learner Stimulus #6 C-spine x-ray

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Learner Stimulus #7 Pelvis x-ray

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Learner Stimulus #8 Right knee x-ray

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Learner Stimulus #9 Abdominal Ultrasound/FAST exam

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Learner Stimulus #10 Lactate: 15.5 mEq/L

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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 unstable multi-trauma patient Critical Action #7: Call the Trauma surgeon for immediate OR resuscitation. NO CT IMAGING! 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

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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 one of the following: NI = Needs Improvement ME = Meets Expectations AE = Above Expectations NA= Not Assessed

Critical Actions
Immediate intubation while maintaining C-spine immobilization Perform a basic neurologic exam prior to giving paralytics Aggressive IVF and blood product administration for hypovolemic shock Perform a FAST exam and recognize intraperitoneal hemorrhage Recognize and immediately reduce knee dislocation, verify pulses are present after reduction Obtain CXR, Pelvis XR & C-spine XR in unstable trauma patient Call the Trauma surgeon for immediate OR resuscitation. NO CT IMAGING! Explain patients condition to the family in the waiting room

NI

ME

AE

NA

Category PC, MK PC, MK PC, MK, PBL PC, MK, PBL PC, MK PC, MK, PBL PC, MK, ICS, SBP ICS, P

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Category: One or more of the ACGME Core Competencies as defined in the SDOT PC= Patient Care
Compassionate, appropriate, and effective for the treatment of health problems and the promotion of health

MK= Medical Knowledge

Residents are expected to formulate an appropriate differential diagnosis with special attention to life-threatening conditions, demonstrate the ability to utilize available medical resources effectively, and apply this knowledge to clinical decision making

PBL= Practice Based Learning & Improvement Involves investigation and evaluation of their own patient care, appraisal and assimilation of scientific evidence, and improvements in patient care ICS= Interpersonal Communication Skills
Results in effective information exchange and teaming with patients, their families, and other health professionals

P=

Professionalism
Manifested through a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population

SBP= Systems Based Practice

Manifested by actions that demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value

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Keywords for future searching functions: Blunt Trauma Knee dislocation Hemoperitoneum FAST exam Hemorrhagic 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: lessons learned 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 abdominal sonography 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 home institution (University of California, San Diego) for our Emergency Medicine Residency Mock oral boards program.

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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 orotracheal intubation.

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

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The provider holding CSpine Immobilization from the head of the bed (after paralytics) may assist the airway operator to improve vocal cord visualization by adding jaw thrust. Griswold, 2011. 2.) Hemorrhagic Shock: Standard treatment for hemorrhagic shock in adults consists of rapidly infusing 2 liters of isotonic crystalloid per ATLS recommendations. If criteria for shock persist despite crystalloid infusion, PRBCs should be infused (5-10 ml/kg). Type-specific blood should be used when the clinical scenario permits, but uncrossmatched blood should be immediately used for patients with hypotension and uncontrolled hemorrhage. O-negative blood is used in women of childbearing age and Opositive 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 Trauma and 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 is the ideal initial imaging modality because it can be performed simultaneously with other resuscitative cares, providing vital information without the time delay caused by radiographs or computed tomography (CT). The concept behind the FAST exam is that many life-threatening injuries cause bleeding. Although ultrasound is not 100% sensitive for identifying all bleeding, it is nearly perfect for recognizing intraperitoneal bleeding in hypotensive patients who need an emergent laparotomy. Robert Reardon, MD. http://www.sonoguide.com/FAST.html

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