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CC: “I think I need stitches”

CC: “I think I need stitches”. A Case of Head vs. Bat. EM Sub-I Presentation Kathy Staats , MS IV. HPI & ROS. 25 M 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.

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CC: “I think I need stitches”

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  1. CC: “I think I need stitches” A Case of Head vs. Bat EM Sub-I Presentation Kathy Staats, MS IV

  2. HPI & ROS • 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.

  3. HPI continued • 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

  4. Physical Exam • V/S: 144/89 76 bpm16rpm99%RA98.8°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 crepitusor step-off of skull or vertebrae. EOMI, MMM, PERRL, ø JVD, øLAD

  5. 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

  6. What should we do next? • For Focused Trauma: • Always ABCs • Disability and Neuro • Exposure • For Scalp Lacerations: • History • PE • Imaging and Consults – • Contrast or No? • Who and Why? • Wound Debridement & Repair

  7. Nexus Criteria NSAID (N with N) • Neuro Deficit • Spinal Tenderness • Altered LOC • Intoxication • Distracting Injury If NOT present, NO radiography Sn: 97-100% Sp: 13%

  8. Canada C-Spine Rule: 3 Parts! • Age ≥ 65 • Extremity Paresthesias • Dangerous Mechanism 1 If present, do radiography If not, onto 2 • Sitting in ED • Ambulating ever • Delayed neck pain • Rear end MVC • No c-spine tenderness 2 If present, onto 3 If not, onto x-ray 3 • < 45° L or R = x-ray • Full ROM = cleared c-spine! • Test active ROM Sn: 91% Sp: 37%

  9. New Orleans Criteria:SHAVEMeAbove the Clavicle • Seizure • Headache • Age > 60 • Vomiting • Etohor Drug Intoxication • MEmory: Persistent anterogradeamnesia • Above the Clavicle-Visible Trauma Sn: 100% Sp: 52%

  10. Canada Criteria: FF G DAMN • Fracture: Suspected open/depressed skull fracture • Fracture : Suspected basilar skull fracture • GCS < 15 at 2 hours post-injury • Dangerous Mechanism • Age ≥ 65 • Memory: Retrograde amnesia from event ≥ 30 min • N/Vomiting ≥ 2 episodes Sn: 100% Sp: 88%

  11. Hospital Course • 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.

  12. Suturing • 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 4.0Vicryl 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 back • 5days post forehead lac for removal & f/u

  13. 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.

  14. Sources • "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 — 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.

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