Flipping EM: Trauma & Wound Care

Welcome to Flipping EM, our flipped classroom case-based learning conference activity! Each conference module we will post clinical cases for your consideration and each learner level (PGY1, 2, 3) will be asked to answer a question about the cases. In order to aid your response, links to journal articles will accompany each question. You will be responsible for reading the articles for your level’s assigned questions and developing an answer to the questions (feel free to seek out other resources as well!). During our scheduled conference time, we will break up into small groups of 6-9 residents (2-3 residents per level in each group) with a faculty facilitator. Each level of learner will discuss their question and corresponding articles and teach the rest of the small group what they learned with the other group members adding their input. Below you will find the cases for this edition which focuses on Trauma and Wound Care. Please be prepared to discuss your articles and questions by conference on 4/6/17!

Case #1

30 M BIBA s/p MVC. The patient was the restrained driver traveling at 65mph when hit on passenger side then crashing into the highway median. +Airbags deployed. The patient recalls most of the events however may have experienced a brief period of LOC. EMS removed the patient from his car and placed him onto a stretcher and placed the patient in a cervical collar prior to transporting him to your ED. Upon arrival, the patient is noted to have a patent airway, clear breath sounds b/l, mentating normally with good perfusion to all extremities, GCS=15, no signs of active hemorrhage or deformity on exposure. VS: T= 37C BP=110/65, HR=95, R=18, O2=98%. 

PGY 1: The patient complains that the cervical collar is very uncomfortable and ask you to remove it. What criteria would you use to determine if the patient may have a clinically significant cervical spine injury? What if the patient had an altered level of consciousness? Would it be appropriate to clear a cervical collar after a negative CT in an obtunded trauma patient?

• Accuracy of the Canadian C-spine rule and NEXUS to screen for clinically important cervical spine injury in patients following blunt trauma: a systematic review
• Cervical spine collar clearance in the obtunded adult blunt trauma patient: a systematic review and practice management guideline from the Eastern Association for the Surgery of Trauma.

PGY 2: You perform a FAST exam which is negative. The FAST and now eFAST exam has become a routine adjunct in the evaluation of the trauma patient. What is the role of the FAST exam in trauma? What are its strengths and limitations? Should its role in the trauma bay be ubiquitous or more limited and if so, to what subset of trauma patients?

• Emergency ultrasound-based algorithms for diagnosing blunt abdominal trauma

• What is the utility of the Focused Assessment with Sonography in Trauma (FAST) exam in penetrating torso trauma? (requires library login)

PGY 3: You complete your secondary survey without evidence of any tenderness, ecchymosis, or other deformity. The trauma attending recommends a “panscan” given the high speed mechanism. Is total-body CT appropriate in this scenario? What evidence is there to support a total-body CT approach compared to selective CT in the evaluation of blunt trauma patients?

• Immediate total-body CT scanning versus conventional imaging and selective CT scanning in patients with severe trauma (REACT-2): a randomised controlled trial (requires library login)
• Systematic review and meta-analysis of routine total body CT compared with selective CT in trauma patients. (requires library login)

Case #2

27 M p/w laceration to his right palm. He reports the injury occurred while he was preparing dinner last night (approximately 18 hours prior to arrival to the ED) while using a steak knife. The patient initially washed the wound with tap water and wrapped it with paper towels but notes that it continued to ooze blood throughout the night into today which is what prompted him to come to the ED. On exam, the patient is found to have a 6cm curvilinear laceration to the palmar surface of the right hand with no significant active bleeding. There are no signs of infection such as erythema, warmth, pus associated with the wound. The patient has full range of motion of his digits and is neurovascularly intact distal to the injury.

VS: T: 37C, BP: 120/80, HR: 85, RR: 16, O2: 100%

PGY 1: Given the time since the injury occurred, would you consider performing primary closure of the laceration at this time? Does the age of the wound impact the risk for infection?

• The impact of wound age on the infection rate of simple lacerations repaired in the emergency department. (requires library login)

PGY 2: You inform the patient that he will require stitches to repair the wound. He states he has a fear of needles and heard of doctors using glue to fix cuts and asks whether that would be an option for him. Is the use of a tissue adhesive an appropriate option for this patient? Why or why not? What are the benefits and limitations to the use of tissue adhesives for laceration repair?

PGY 3: You successfully repair the laceration without complication. Should this patient receive antibiotic prophylaxis prior to discharge? What are the indications for antibiotic prophylaxis in the setting of acute traumatic lacerations?

• Evidence-based emergency medicine/critically appraised topic. The role of antibiotic prophylaxis for prevention of infection in patients with simple hand lacerations. (requires library login)
• Antibiotic prescribing practices of emergency physicians and patient expectations for uncomplicated lacerations.

Feel free to utilize additional resources to support your responses and further the discussion of the topics raised in the cases! Please leave any questions or comments below. Thanks!