Case Study Trauma Example 1 LOWER EXTREMITY / PELVIC FRACTURE Literature Review Trauma is any physical damage to the body caused by violence or accident or fracture etc. that results in a wound or injury brought on by an external force. The external force in point is High-energy trauma by a pedestrian versus motor vehicle. Usually femur fractures, lacerations and multiple tissue injuries are a few of the wounds experienced by trauma patients. If several parts of the body are injured simultaneously significant bleeding can result. Which is why trauma is one of the leading causes of death if proper patient assessment and interventions aren't meant within the "golden hour". In emergency medicine the golden hour is the first sixty minutes after an accident or the onset of acute illness. The victim's chances of survival are greatest if he or she can be in the operating room within the Golden Hour. According to Wikipedia, the structure of the lower extremities extends from the hip to the ankle, and including the thigh, the knee, and the cnemis]. The largest bone in the human body, the femur, is in the leg. Legs are often used metaphorically in many cultures to indicate either strength or mobility. Legs are often used for standing, walking, jumping, running, kicking, and similar activities, and are a significant portion of a person's mass. Another injury spot of the patient was the pelvis. The pelvis is the bony structure located at the base of the spine. The pelvis incorporates the socket portion of the hip joint for each leg or hind leg forms the lower limb girdle of the skeleton. The pelvic girdle is formed from 2 pelvic bones joined to the sacrum (base of spinal cord). In front the pelvic bones are held together by the pubic symphysis joint. This joint allows only slight bending movement, but it softens and becomes more flexible in a female giving birth. The onsets of fractures to the lower extremities are caused by automobiles accidents and other high-energy impacts. These fractures are often, associated with the soft tissue trauma, significant hemorrhage and at times open wounds. The amount of energy dispensed to the bone and soft tissue at time of injury is most important on determining the treatment and outcome of an open fracture. When the patient has suffered multiple injuries, it is important to recall the principles of trauma assessment and first identify and focus on life-threatening injuries and not be distracted by deformities. Once all life-threatening injuries have been managed it is important to assess and stabilize all limb injuries. Immobilizing the limbs before movement of patient prevents further damage and reduces the amount of pain and discomfort. The ultimate goal is to restore the patient to their pre-trauma status, or as close to that as possible, in as little time as possible. With this in mind, that's why it is important to provide prompt and appropriate care in the prehospital setting. Not all patients present the same or even are able to localize the pain when it comes to multiple injuries. Therefore there are certain signs you should be aware of: vital signs, pain in extremity, pale extremity, diminished distal pulses, paralysis of extremity, external hemorrhage, signs of shock and DCAP-BTLS. In the prehospital care setting it is highly important to recognize the signs and symptoms of the injured in order to properly triage the patient. The greatest potential of harm comes from under triage. Under triage means the patients' injuries were underestimated and the patient was transported to a facility that did not have adequate resources to manage the patient. Improper triaging of the patient can result in delay of appropriate care and additional morbidity and mortality. There are four things the prehospital provider must consider: the patients potential for serious injury, determine best available facility, transport time and decide best mode of transportation. If ever unsure of transport or severity, always error in favor of the patient. Remember time is critical! Treatment for a patient begins the moment EMS arrives until full recovery from hospital or medical examiner pronounces the patient dead. Always assess: ABC's (secure a patent airway if it calls for one), control any life threatening injuries or bleeding (direct pressure or elevation), c-spine, immobility consideration and Transport. Once arrival to the hospital, the patient go through a series of predetermine set of laboratory test known as trauma labs or trauma lab panels, which include rectal exams, CT scans, X-rays, blood test and are often referred to as chemistry, hematologic, and coagulation profiles. Depending on the severity of injury will determine what happens next. Injuries that involve the lower extremities and pelvis that present as closed or open fractures, avulsions, ruptures, etc must be cleansed, manual traction and surgery I suture to fix. The treatment for broken bones follow one rule: the broken pieces must be put back into position to prevent movement of the bones from out of place until they are healed. The specific method of treatment depends on the severity of the break and whether it is open or closed. The following treatments are used for various types of fractures: cast immobilization, functional cast or brace, traction, open reduction and internal fixation, and external fixation. All of these treatments can lead to a completely healed, well aligned bone that functions well The third step is recovery and monitor for infections. Antibiotic therapy is determined for use of trauma patients by the age of the wound, type, location and degree of contamination. Patients who follow doctor's orders tend to fare better then those who don't. The outcome for a patient who has experienced such trauma will need to go through psychological and physical therapy. They need to learn how to cope with their emotions and process the possible of never being able to walk, stand, kick, run, etc. However, if the surgical team is able to salvage the multiple injuries then the patient will need to under go physical therapy. Physical therapy is concerned with identifying and maximizing movement potential, within the spheres of promotion, prevention, treatment and rehabilitation. It involves the interaction between physical clients, families and caregivers, in a process of assessing movement potential and in establishing agreed upon goals and objectives using knowledge and skills unique to physical therapists. With time the patient will regain some muscle strength and movement but the patient will never have the range of motion they had before the accident. Case History Patient is a 23 year-old white male, presented with multiple long bone fractures, lacerations to genital area and avulsions to L and R hamstrings S/P MVC. General impression is patient is unstable, skin cool and pale, breathing on own. Appears to be in extreme pain. Lower portion of body has multiple injuries. Patient was pushing his vehicle out of the road when struck by second vehicle at approximately 60 mph, crushing him between vehicles. Patient states feels better when traction is applied. Distal pulses resume, feet color returned pink and warm. Quality of pain is sharp and intense, radiating to pelvis and lower extremities bilateral, 10+ on 1 - 10 scale and is constant. Patient denies loss of consciousness. A&Ox4, answers questions appropriately. Skin diaphoretic, cool and pale. Discoloration/bruising to scrotum and penis, with laceration to scrotum R side. L and R femur (bilateral) compound Fx along with bilateral tibia compound Fx and R Fibula Fx. Bilateral hamstring open wounds and major blood loss. Pelvis slightly tilted to the R. Breath sounds CTA =. No distal pulses in lower extremities, patient able to move toes, states sensation in lower feet. Once traction applied to R & L lower extremities distal pulses resumed. Arrived via Rescue fully packaged. Pain management, injuries cleansed and dressed, X-rays and CT in ER. Taken to OR following CT scan. V/S 2210 18R 110W 103/61 E PERRL Pale, diaphoretic, cold 15 100% 2215 20R 99W 121/60 E PERRL Pale, cold 15 100% 2220 20R 84W 132/73 E PERRL 15 100% References • http://wordnet.princeton.edu/perl/webwn • www.dental.mu.edu/ oralpath/ opgloss3.html • http://en.wikipedia.org/wiki/Golden_hour upload.wikimedia.org/wikipedia/ commons/thumb/ • http://en.wikipedia.org/wiki/Pelvis • http://members.aol.com/ Attic21 I Anatomy I pelvis.html • Atkinson, Carole, et al. Specific Injuries: Diagnosis, Operative, Treatment, and Management. Missouri: Mosby, 1999. • Marcum, Larry, et al. Priorities in Multiple Trauma. Maryland: Aspen 1979. Case Study Medical Example 2 DIABETES Literature Review In the United States, 20.8 million people, or approximately 7% of the population, have some form of diabetes (ADA #1, Section 1). Out of those cases, 176,500 are under the age of20(NDIC #3, Section 1). Diabetes affects every race, ethnicity, and age group. "Diabetes is a disease in which the body does not produce or properly use insulin" (ADA #1, Section1). The insulin hormone is a necessity to make the fuel for the body to function properly. Insulin is what "converts sugar, starches, and other food into energy" (ADA #1, Section 1). There are three main types of diabetes, each affecting the body's insulin source differently. These types are: Type 2 Diabetes, Gestational Diabetes, and Type 1 Diabetes. Type 2 Diabetes develops when the body does not utilize its insulin properly, and there is usually a decreased level of insulin production as well. This type can be controlled by many different means. Depending on the patient, Type 2 Diabetes can be controlled by diet, oral medication, insulin injections, or a combination of these. The majority of diabetic people have this type of diabetes (ADA #1, Section7). Gestational Diabetes develops during pregnancy, when the mother has no previous diagnosis of diabetes. It usually resolves once the baby is delivered (ADA #1, Section 8). Type 1 Diabetes has also been called "juvenile diabetes" or insulin dependent diabetes. Onset is usually before the age of 20 years, and these patients must rely on some form of insulin administration to survive. In Type 1 Diabetes the body no longer produces any insulin. The beta cells of the pancreas have been damaged in some way, and these are the only insulin-producing cells in the body. Insulin must be injected at regular intervals so the body can function properly. Type 1 Diabetes is a lifelong struggle for its victims, since most are diagnosed during childhood. This differs from Type 2, which is usually diagnosed in adulthood (NDIC #1, Section 2). Complications from any form of diabetes can be acute, or long-term, and very detrimental to the body. Some long-term complications include: heart disease, stroke, hypertension, blindness (retinopathy), amputations of limbs and digits, kidney disease (nephropathy), nervous system diseases (neuropathy), and various other problems. There are also life-threatening complications that include: diabetic ketoacidosis (DKA), and hyperosmolar (nonketotic) coma (NDIC, Sections 1-9). All diabetics, despite how well or poorly they control their diabetes, will experience some form of complications from the disease. How fast those complications progress depends on how well their blood glucose is managed. Often people are not diagnosed with diabetes until they experience one of these life- threatening conditions, and end up hospitalized. Hypoglycemia is another complication of diabetes. No matter how well a person manages his/her blood glucose, at some point in time, he/she will experience this condition. Hypoglycemia occurs when the blood glucose level falls below the healthy range. Some patients may be asymptomatic, while others may experience very severe signs and symptoms. The person may feel shaky or dizzy, may be diaphoretic or pale and clammy. They may complain of a headache or feeling hungry. Changes in mental status may occur. They may appear lethargic or sluggish, and the symptoms may mimic a stroke (ADA #2, Sections 1-3). The brain relies on glucose to function properly, and without it, damage can occur, sometimes in detrimental proportions. If not treated rapidly, signs and symptoms become more pronounced as the blood glucose level drops, and can eventually lead to coma or death. Case History "Patient A" is a 24-year-old black female. She presented to rescue with somewhat slurred speech and lethargy. Her coworkers stated she had been slurring her words and then "passed out" approximately 5 minutes prior to arrival of rescue. The patient was sitting up in a chair, mumbling quietly, with her eyes closed. She appeared very lethargic, and was barely able to hold her head up. Upon questioning, she was oriented x 3, with a GCS of 14. She was able to stated that she had been a Type 1 diabetic for the last 5 years, and that she was 10 weeks pregnant (gravida 2/ para 1). She stated she had eaten a large breakfast and came to work. She took her usual dose of regular insulin at noon, and ate a large lunch immediately after. She stated she started "feeling funny" at around 2pm. VS were taken (BP 110/66; HR 76, strong & regular; RR 18, regular & adequate; 02 sat 99% on RA). PERRL, skin was warm and dry, with no diaphoresis noted. Lungs sounds are CTA bilaterally. Initial blood glucose on accucheck =20. She was administered half of a tube of oral glucose, and then Patient A refused to finish the other half, stating, "It's nasty." After multiple unsuccessful attempts to start an IV, the patient family agreed to finish the oral glucose. Patient was transported to the hospital. In transit, the patient was placed on 02 at 4LPM, and accucheck was rechecked which was 30. She was given another tube of oral glucose. VS were rechecked (BP 116/68; HR 80, strong & regular; RR 16, regular & adequate; 02 sat 99% on 4LPM NC). PERRL, and GCS was now 15. Skin remained warm and dry. Transport time was approximately 6 minutes. By the time the patient arrived at the hospital, she was alert, awake, and talking clearly, moving all extremities with regular strength and ROM. She was able to walk from the stretcher to the bed with no assistance. References American Diabetes Association (ADA #1). (2007). Diabetes.org. Retrieved April 14, 2007, from http://vvww.diabetes.org/about-diabetes.jsp American Diabetes Association (ADA #2). (2007). Diabetes.org. Retrieved April 14, 2007, from http://www.diabetes. org/type-2-diabetes/hypoglycemia. j sp National Diabetes Information Clearinghouse (NDIC #1). (2005). "What Is Diabetes". Diabetes.niddk.nih.gov. Retrieved April 14, 2007, from http://diabetes.niddk.nih.gov/dmJpubs/statistics/index.htm
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