Appendix/Supplemental materials

Figure 1:Example Oral Case Simulation Materials for Multi-Trauma Case

Initial information given to examinee:

Name: Antonio BagadaciaAge: 28

Method of Arrival:Ambulance

Chief Complaint:Motorcycle crash

Initial VS:HR: 121RR: 6BP: 85/40O2SAT: %

*Relevant laboratory test results available on pre-printed sheets for examinees if requested.

*Portable chest radiograph, electrocardiogram, and representative cuts from Head CT scan also provided if requested.

Case summary for instructors:

HPI:

  • Per ambulance staff, unhelmeted driver of scooter struck the outside brick wall of Café Le Giubbe Rosse at high speed.
  • Positive loss of consciousness
  • Confused, lethargic on scene
  • Intubated by pre-hospital providers

PMHx:Unknown

PSHx: Unknown

Meds:Unknown

Allergies:Unknown

FamHx:Unknown

SocHx:Unknown

Physical Exam:

General:

  • Missing Vitals: T 36 C, O2 Sat 65%
  • Unresponsive, intubated, on long spine board in cervical spine immobilization, agonal respirations, ventilations assisted with bagging

A:Endotracheal tube in oropharynx

B:O2 Sats 65%, No breath sounds over anterior chest bilaterally, no end tidal CO2 color change

C:Pulses equal but diminished bilaterally

D:Does not open eyes to pain. No verbal response, flexes extremities to pain

HEENT:

  • Large left parietal scalp hematoma
  • Left pupil 8mm, right pupil 4mm, sluggish
  • Tympanic membranes clear
  • Midface stable

Neck: Immobilized, trachea midline

Back: Non-tender, no stepoffs, deformities

Chest: No BS's on initial exam, Normal, equal BS's after re-intubation

CVS: Tachycardia, no murmur, rub, gallop

Abd: Firm, distended, tender, decreased bowel sounds

GU: Pelvis stable, no trauma to genitalia

Rectal:Normal tone, no blood

Ext: Normal except pulses as already noted. No deformities.

Skin: Multiple bruises and abrasions to head, chest, and abdomen

Neuro: Glascow coma scale =3, No eye opening, no verbal response, flexes extremities to pain

Diagnostic Studies:

  • WBC 12, Hgb 9.0, Hct 25, plt 250
  • Na 136, K 3.8, Cl 104, CO2 21
  • BUN 57, Cr 0.8
  • Glucose 95
  • Type and Cross x 4 Pending
  • Calcium/Magnesium Normal
  • Liver function tests Normal
  • Amylase/Lipase Normal
  • PT/PTT Normal
  • Cardiac Enzymes Normal
  • Alcohol level 70 mmol (280 mg/dL)
  • Toxicological Screen: Otherwise Negative
  • Arterial blood gas (ABG): Post-intubation: pH 7.33, pO2 400, pCO2 41,

HCO3 18, FIO2 100%

  • ABG #2: after moderate hyperventilation, correcting pCO2:
  • 7.39/350/30/Bicarb17
  • Urinalysis: Negative for blood
  • Electrocardiogram: Sinus tachycardia
  • Portable chest X-Ray: No pneumothoraz, rib fractures
  • Pelvis X-Ray: No fractures
  • FAST Ultrasound exam: Positive for free fluid in abdomen, no tamponade
  • CT Head: Large left epidural hematoma with mass effect15

Treatment and Interventions:

  • Diagnose esophageal intubation and remove tube.
  • Perform rapid sequence intubation and verify tube placement (End tidal CO2, BS equal, no BS over stomach, check post-intubation portable CXR)
  • Initiate 2 large bore IV's with rapid infusion of 2L NS or LR
  • Blood transfusion for shock (if candidate does not give blood, blood pressure continues to drop)
  • Insert an orogastric tube and foley catheter (prior to Diagnostic peritoneal lavage if DPL performed)
  • Perform FAST exam and/or DPL to diagnose peritoneal hemorrhage
  • Consult surgeon for operative treatment of intra-abdominal injuries
  • Obtain stat head CT to diagnose EDH
  • Consult neurosurgery to treat EDH
  • Obtain ABG and correct pCO2, raise HOB, +/- start mannitol for CHI
  • Administer Td 0.5cc IM

Disposition:To O.R. for epidural hematoma evacuation and exploratory laparotomy

Interpersonal relationships:

  • Hold medics if possible
  • Volunteer to speak with family if family present

Critical Actions:

  • Diagnose esophageal intubation and reintubate
  • Diagnose hemorrhagic shock and initiate fluid resuscitation +/- bloodtransfusion
  • Diagnose epidural hematoma and consult neurosurgery for intervention
  • Diagnose abdominal trauma by US or DPL and consult surgery for operative

exploration and repair