Abdominal Trauma, Dr. McKinney

Penetrating trauma

• OR if unstable, peritonitis, evisceration, evidence of GI bleeding, GSW traversing peritoneum or retroperitoneum, or penetrating object still in place on arrival
• Local exploration of anterior stab wounds can identify peritoneal violation
• X-ray can screen for retained foreign bodies, free air under the diaphragm, or coexisting thoracic injury
• FAST uses peritoneal free fluid as a marker for injury and cannot specifically check for retroperitoneal, diaphragmatic, solid-organ, or hollow viscus injuries.
• DPL, although not done frequently, can be performed in patients who do not have indications for immediate laparotomy and who have an unreliable or equivocal exam.

Blunt trauma

• unstable with positive FAST/DPL > Massive transfusion protocol, OR
• stable with positive FAST/DPL > +/- blood products > CT
• injuries that may be missed on CT : pancreatic, bowel/mesentery, bladder rupture, and diaphragm rupture.
• diaphragm injury: rare, may be noted on CXR by the presence of bowel in the chest cavity, Left-sided injury more common than right because the liver is protective. Left-side injuries typically require operative intervention to prevent the herniation of abdominal contents.
• seatbelt sign think hollow viscous injury, CT has poor sensitivity for diagnosis. Discuss case with trauma, patient will likely receive admission for serial abdominal exams
• Splenic injury: most common injured organ in blunt trauma. Lower grades are typically nonoperative and are treated with observation
• ecchymosis over the flank (Grey Turner sign) or periumbilical region (Cullen sign) are suggestive of retroperitoneal hemorrhage

Genitourinary Trauma, Dr. Kuzel

• kidney: most common injured GU organ, often see gross hematuria, flank ecchymosis, and lower rib fractures. obtain CT Abd/pelvis W, GRADE I-III usually non op, discus with trauma
• ureteral: 90% penetrating, often does not present with hematuria. CT abd/pelvis W> consult urology > surgical repair
• bladder: associated with pelvic fractures, look for hematuria and lower abdominal/scrotal bruising.  Gold standard test: cystogram. Extraperitoneal injuries managed w/ bladder catheter drainage alone, intraperitoneal > surgical exploration/repair
• urethral injuries: Males>Females,straddle injury mechanism, and pelvic fractures. Look for blood at meatus, swollen penis. Single attempt at foley may be attempted. Diagnosis made with retrograde urethrogram. Injuries either posterior vs anterior. Consult urology, Suprapubic catheterization may be required initially, may need OR
• testes/scrotal – blunt: obtain Doppler US, if testicular rupture > OR. Penetrating: often undergo immediate exploration
• penile: fracture- cracking sound, pain, discoloration > US. Amputation -have 8-12 hours for reimplantation

Chest Trauma, Dr. Selk

• Blunt aorta injury : majoirty die in the field. Check for asymmetric pulses, diastolic murmur. CXR followed by CT chest W.  Tight HR and blood pressure control, esmolol often first choice .Surgical or endovascular repair ultimate treatment for a traumatic aortic injury
• pulmonary contusions – SOB, tachypnea, might see patchy infiltrate on CXR, better seen on CT, tx: pulm toilet, mech ventilation in those with severe respiratory compromise
• cardiac contusions – get EKG. if abnormal, get cardiac biomarkers. If isolated injury, okay to discharge
• clavicle fracture – if less than age 2, think NAT
• hemothorax – consider autotransfusion in shock

EMS Radio Communications, Dr. Orthober

• various type of EMS agencies (fire based, private, hospital based, third service, provider, community based) and levels of providers: first responder, EMT, EMT advanced, paramedic
• typical EMS ambulance staffing – BLS crew (EMT + EMT) or ALS crew (EMT + Paramedic)
• Things paramedics can’t do – Chest tube, surgical cric, perimortem c-sec, central lines
• a paramedic shall not terminate in hypothermia, cold water drowning, lightning/electrical injuries
• in arrests, ask for end–tidal C02, ROSC unlikely if less than 10
• for trauma patients,, ask about hypotension and achycardia, GCS?
• for medical patients, use vitals and mental status to help guide room 9 decision
• for stroke patients: LKN? anticoagulated? collateral riding in with them?
• general pediatric considerations – penetrating trauma > 13 years to ULH (or look like an adult), blunt trauma > 15 years to ULH,  although this is a moving target
• nasal intubation: remember phrase, “if in ain’t hubbed, it ain’t in”
• don’t discount mechanism on radio
• Kentucky EMS DNR- has to be original copy – obligated to transport to hospital without one of these

Survivalist’s Guide to the Pediatric ED, Dr. Lund

• Add order sets to favorites, get HPI and discharge do phrases
• Admissions: bed slip > tigertext > talk to admit team > choose dispo > order “ready for dispo”
• asthma: avoid decadron first time wheezers, get xray first to evaluate for neck mass
• neonatal fever (familiarize age considerations for testing/mgmt)
• neutropenic fever- CBC, blood cultures, cefepime within 1 hour
• healthychildren.org – good resource for normal newborn habits
• toxic, lethargic, irritable – use the descriptions with caution
• Tylenol 10 to 15mg/kg/dose, ibuprofen 5-10mg/kg/dose (>6 months of age)
• high dose amoxicillin (90mg/kg/day, BID) for AOM, pneumonia
• know 4-2-1 rule for MF calculation, typically use D5NS or D51/2NS

SANE Services, Amanda Corzine

• male or female victims of sexual assault age 12 and older (as long as have menses)
• Rape kit collection within 96 hours (4 days) of assault
• currently have 100% SANE coverage by nursing staff, at all of UofL health facilities and all Norton ERs
• same exam whether reporting or not reporting to police, kits are kept for 1 year
• level of alertness required for exam/consent. Search warrant for unconscious patients if suspicion high
• can go on to EPS if waiting for sane exam and otherwise medically clear, do not delay transfer
• always collect patient underwear, external and internal vaginal swabs with vaginal assault
• unlikely will have 24/7 SANE coverage when leaving residency, try to observe and familiar with an exam process now!
• toulidine blue dye – adheres to injured tissue helps injury identification by as much as 60%
• HIV PEP regimen Truvada and isentress (pharmacy can help with prescriptions at discharge)
• do NOT accept a transfer of patient for sole purpose of SANE exam