Maureen Harrahill

Trauma case management: An extension of the trauma coordinator role

Case management is a process of linking services by assigning accountability to an identified individual(s) for coordinating a patients care across a continuum of care. The goal of case management is to ensure cost-effective, nonfragmented quality care. Adoption of the case management role by the trauma coordinator can have a positive impact on both patient care and resources.

An Unusual Case of Cerebral Venous Sinus Thrombosis in a Trauma Patient

One morning in early August, a friend went to the home of a coworker who failed to show up to work for the third day in a row. There he found the front window of the house broken and the patient lying on the floor in the living room. When the EMS team arrived, the patient was conscious but confused and mildly agitated. He shared that he had diabetes and had a seizure disorder but could provide no details on the event that led him to the floor of his house. “I trashed my head,” he said repeatedly. On examination, the paramedics found a 1-inch laceration on the occiput with an associated hematoma, a left eyelid abrasion, and multiple abrasions on his legs. His pupils were reactive but deviated to the right. The patient had both defecated and urinated on himself. His blood glucose level was 158 mg/dL, blood pressure was 127/58 mm Hg, and heart rate was 80 beats/min. Because of the unclear history and the obvious injury to the head, the paramedics entered the patient into the trauma system. The patient arrived at the hospital on a backboard and wearing a cervical collar. His pupils continued to deviate to the right but were briskly reactive. He did not blink appropriately to threat—when the physician rapidly brought his hand close—and he could not see fingers in front of his eyes. His cervical spine was mildly tender to palpation. A computed tomography (CT) scan was obtained, and we were surprised to see metallic bullet fragments on the head and the cervical spine scans. His head CT scan showed these fragments within the occipital region along with associated edema and contusions. In addition, the scan was concerning for a possible injury to the superior sagittal sinus. On the cervical spine CT scan, the radiologists could trace the trajectory of a bullet, entering the right lateral neck and contacting and breaking the spinous processes of C3 and C2 before lodging in the subcutaneous soft tissues of the posterolateral left side of the neck. They did not see any metallic fragments within the spinal canal or in the region of the carotid or vertebral vessels. Because of their concern of injury to the patient’s cerebral venous system, the team performed angiography. The superior sagittal sinus was found to be thrombosed, but the neck vessels were uninjured. The neurosurgeons took him to the operating room for exploration and washout of the wound. They found no evidence of cerebrospinal fluid leak. Postoperatively, as the patient’s mental status cleared, it became clear that he had profound vision loss. He had some vague light perception and his pupils were sluggish but reactive. He still had a rightward gaze preference. The ophthalmologist called his vision loss “profound cortical vision loss” because of the anatomic location of his injury. The rest of the patient’s hospital course was uneventful. His spine fracture was treated in a cervical collar. In the follow-up clinic, he has had some minimal return of his vision. He is able to see shapes and motion and to identify brightness in terms of shades of gray.

Cardiac contusion: Two case vignettes * **

When patients with blunt chest trauma and suspected cardiac contusion are brought to the emergency department, focus on detecting subtle signs of myocardial dysfunction. Obtain the important first EKG, monitor for arrhythmia development, and assess for signs of failure of the right side of the heart.

Flail chest: a nursing challenge.

Caring for a patient with a flail chest poses a significant challenge to the ED nurse. Performing serial evaluation, complicated pain management, and diligent pulmonary toilet will put your nursing skills to the test! Finding the time to do it in a busy emergency department ... well, thats a topic for another article.

Unexplained car crash: what you should consider

A 30-year-old woman crashed her car into a parked car after leaving work. She was restrained, and the car’s airbag did not deploy. When the paramedics arrived, she was confused and unable to answer questions appropriately. En route to the hospital, she had tonic-clonic seizure that lasted approximately 45 seconds. Upon arrival at the emergency department, she was unresponsive. Her vital signs were as follows: blood pressure, 197/73 mmHg; heart rate, 133 beats per minute; respiratory rate, 18 breaths per minute (unassisted); and oxygen saturation, 96% on a non-rebreather mask. Her blood sugar was measured at 118 mg/dL, and her blood alcohol level was negative. The team intubated her to protect her airway and obtained a head computed tomography (CT) scan. This CT scan showed a small amount of intracranial hemorrhage along the tentorium with no mass effect. Her father arrived and reported that she has a history of depression for which she takes medication, but otherwise is healthy and has had no previous seizures. She was admitted to the ICU with a neurosurgery consult. The neurosurgeons prescribed phenytoin for seizure prophylaxis, and she had a repeat head CT scan that showed no increase in the hemorrhage. She was easily extubated the following morning. The next day, she was feeling well, eating a regular diet, and ambulating independently. No additional injuries were found and she was discharged home with an anti-seizure medication. When she came for her clinic appointment a week later, she stated that she did not know why she crashed her car. She remembered feeling “poorly” at work the day of the crash because of a headache. After further discussion, she recalled having left-sided headaches for several months before her crash, which were increasing in intensity. The physician obtained a magnetic resonance imaging scan that showed a thrombosed left transverse sinus with vasogenic edema. In reviewing her previous head CT scans, the radiologist reported that a superimposed left sinus thrombosis might be obscured by the hemorrhage. The patient was readmitted for anticoagulation and further work-up. Although the reason for a car crash is often known, an unexplained single-car crash should be a red flag to the treatment team. Several underlying causes should be ruled out. Referred to the as “the 6 S’s of single-car crash,” underlying causes may be seizure, sugar, stroke, syncope, suicide, substances, and sleep. Let’s start the discussion with seizures. Certainly, a sudden seizure can cause a patient to crash his or her car. In a survey of emergency physicians, new seizure frequently was rated as the reason for loss of consciousness while driving. One study found that 0.2% of all fatal car crashes were related to drivers having seizures. If, as was reported with this patient, seizures were reported at the scene, it should be considered as a possible cause of the crash. Furthermore, a complete history should be taken to determine the source of the patient’s seizures, especially if the patient had not previously had seizures. Another potential cause of a crash is confusion related to hypoglycemia. A study by Clarke and colleagues in 1999 found that patients with type I diabetes may have poor judgment from low blood glucose, thereby affecting driving or the decision to drive. Furthermore, this study found that diabetics may still drive even if they are aware their blood glucose level is low. While the risk of a diabetic crashing his or her car may not be significantly higher than that of the general population, it clearly is a possible cause of motor vehicle crashes and should be addressed in a patient who possibly has hypoglycemia. Many prehospital providers routinely perform a spot blood glucose check; if it is not done in the field, it certainly should be done in the emergency department in injured patients. Stroke is the third possible cause of unexplained motor vehicle crash. In this category, we can include thrombus, Jean Mullins is a Nursing Student, University of Minnesota.