CC: “I think I need stitches”

A Case of Head vs. Bat

EM Sub-I Presentation Kathy Staats, MS IV

25M brings self to ED one hour post blow to the head with aluminum baseball bat.

Pt hit once on head Deflected another attempt w/left hand. Pt denies loss of consciousness or

memory/ dizziness/ lightheadedness/ change in vision or hearing/ tinnitus/ nausea/ vomiting/ difficulty or change in breathing.

HPI & ROS

Pt reports HA 8/10 throughout head “Extreme pain” around laceration Pt reports minimal tearing of

the eyes and a runny nose ROS otherwise unremarkable Pt reports most recent tetanus

shot in 10/2011 PMH: Pt denies history of concussion,

surgeries, or chronic conditions. NKDA. No current medications. SH: Social smoker and drinker

HPI continued

V/S: 144/89 76 bpm 16 rpm 99%RA 98.8°F

Gen: Well-nourished male, A&Ox3 HEENT: 2-inch, non-bleeding linear laceration

above left eyebrow with 0.5-inch lac perpendicular to the major injury. Laceration extends to intact galea.

No battlesign/raccoon eyes. No fluid from ears, no gross crepitus or step-off of skull or vertebrae. EOMI, MMM, PERRL,

ø JVD, ø LAD

Physical Exam

Neuro: CN II-XII intact. Grossly normal gait. 5/5 strength in all limbs. Sensation present & similar in all limbs. Negative Romberg’s test.

Extremities: Point tenderness on dorsal hand surface of left thumb. Decreased ROM in all directions. 3/5 Strength of thumb.

CV/Pulm/GI: RRR nl S1S2, CTA B/L, +BS, -TTP

For Focused Trauma:◦ Always ABCs◦ Disability and Neuro◦ Exposure

For Scalp Lacerations:1. History2. PE3. Imaging and Consults –

a. Contrast or No? b. Who and Why?

4. Wound Debridement & Repair

What should we do next?

NSAID (N with N)Neuro DeficitSpinal TendernessAltered LOCIntoxicationDistracting Injury

Nexus Criteria

If NOT present, NO radiographySn: 97-100% Sp: 13%

Age ≥ 65 Extremity Paresthesias Dangerous Mechanism

Canada C-Spine Rule: 3 Parts!

1 If present, do radiographyIf not, onto 2

Sitting in EDAmbulating ever Delayed neck painRear end MVCNo c-spine tenderness

23

If present, onto 3If not, onto x-ray

Test active ROM < 45° L or R = x-rayFull ROM = cleared c-spine!

Sn: 91% Sp: 37%

SeizureHeadacheAge > 60VomitingEtoh or Drug IntoxicationMEmory: Persistent anterograde amnesiaAbove the Clavicle - Visible Trauma

New Orleans Criteria:SHAVE Me Above the Clavicle

Sn: 100% Sp: 52%

Fracture: Suspected open/depressed skull fracture

Fracture : Suspected basilar skull fractureGCS < 15 at 2 hours post-injuryDangerous MechanismAge ≥ 65Memory: Retrograde amnesia from event ≥ 30 min

N/Vomiting ≥ 2 episodes

Canada Criteria: FF G DAMN

Sn: 100% Sp: 88%

Case discussed w/attending. Plan to CT head, and suture and release if benign read.

Hours later, CT has not been read and radiology cannot be reached. Next shift attending reviews CT w/medical student and no abnormalities are noted. Pt is sutured and prepared for discharge.

Hospital Course

Lidocaine w/epi on face (before irrigation): ◦ Max dose 7 mg/kg ≈ Given 4 ml locally ◦2 ml as nerve block in supraorbital notch

How much water & what kind for irrigation? ◦60 ml/cm ≈ 240 ml of clean H2O (NaCl, tap, etc)

Sutured inner & outer layers:◦5 stitches with 4.0 Vicryl on inner layer, ◦16 stitches with 5.0 Nylon on skin◦ Can be left open to air, cleaned with soap and water

When to come back/why to come backo 5 days post forehead lac for removal & f/u

Suturing

Original attending of case reviews CT “Mildly depressed fracture anterior wall left

frontal sinus. Soft tissue defect of left frontal scalp.”

ENT is consulted, but pt leaves AMA prior to exam.

Nine days later pt returns to ED for suture removal. Laceration is healing well, with no swelling/ erythema or associated pain.

- ROS, no HA/dizziness/lightheadedness/rhinorrhea.

Appointment is scheduled with ENT for following day. Pt does not attend.

"Assessment and Management of Scalp Lacerations." UpToDate. Web. 18 July 2012. <http://www.uptodate.com/contents/assessment-and-management-of-scalp-lacerations?source=see_link>.

"The New England Journal of Medicine." Validity of a Set of Clinical Criteria to Rule Out Injury to the Cervical Spine in Patients with Blunt Trauma â NEJM�� . Web. 18 July 2012.

Stiell, Ian G., et all. "The Canadian C-Spine Rule versus the NEXUS Low-Risk Criteria in Patients with Trauma." New England Journal of Medicine 349.26 (2003): 2510-518. Print.

Sources