Pre-Hospital Designation: This is a moderate trauma brought in by ambulance.

Transcription

1 Date of Service: [DATE]. Service Provided: Trauma Run Time: 07:17. Pre-Hospital Designation: This is a moderate trauma brought in by ambulance. Events: As follows, this 44-year-old male who was apparently assaulted last night. He went home after the incident, slept off and upon awakening today, his friends noticed he had multiple lacerations and brought him to the hospital. The patient arrives complaining of headache and pain in the hand, he reports no visual disturbances. He had positive EtOH. Allergies: None. Medications: None. Past Medical History: None. Past Surgical History: None. Physical Examination Vital Signs: On arrival, heart rate of 100, blood pressure 110/72, respiratory 16, temperature 36.8, and pulse oximetry 100% on 15 L. HEENT: Comprehensive physical exam reveals on the head ptosis of the left eye, left eye ecchymosis, bleeding from the left ear with laceration to the pinna. Right lower lip laceration involving the vermillion border, 1 cm laceration underneath the left eye. He has 2 stab injury to the neck. He has also very large 4 cm laceration on the top of the head anterior to posterior. Neck: 2.5 cm laceration, no hard signs of vascular or aerodigestive injury. Chest: Clear. Abdomen: Nontender. Musculoskeletal: Multiple stab wounds to the left hand. Two superficial stab wounds to the right hand. Genitalia and Perineum: Normal. Back: Normal. Neurological: Alert and oriented x3, cannot remember the events. Vascular: 2+ with the positive radial pulse on his left hand. GCS was 15. Diagnostic Data: Diagnostic workup included chest x-ray showed some bilateral apical haziness, left-hand x-ray that showed no fractures. CT of the head, C-spine, abdomen, pelvis, and CT of the neck as well as CT of the orbits and face that showed number of facial fractures, but most notably a left temporoparietal fracture without any evidence of intracranial bleed. The abdomen and pelvis was preliminary negative. The CTA showed no vascular injury. In addition, the FAST scan was negative. Further diagnostic workup include H and H 12.9 and ( ). EtOH is 173. Toxicity screen was negative. UA negative. Diagnosis and Plan: This is a 44-year-old male status post multiple stab wounds and facial fractures. At this point, he will go to the operating room urgently for neck exploration to rule out aerodigestive injury. In addition, we will get a neurosurgery consult for skull fracture, plastic consult for the facial lacerations, Ortho consult for hand lacerations, and Ophthalmology consult for the ptosis and eye swelling.

2 Date of Consultation: [DATE] Service Provided: Plastic Surgery. Consulting Service: Emergency Room and Trauma. Reason for Consultation: Multiple lacerations notably of the laceration of the left ear, left lower eyelid, and lower lip. History of Present Illness: Mr. [NAME] is a 45-year-old man who was assaulted the night previous to admission to the emergency room. He was intoxicated at that time, and cannot remember the details of the assault; however, he appears to have multiple stab wounds to the head, neck, hands, and face. Past Medical History: The patient has no past medical history. Past Surgical History: The patient has no past surgical history. Medications: The patient takes no medications. Allergies: The patient has no allergies. Social History: The patient does use alcohol. Physical Examination Vital Signs: The patient is afebrile. His vital signs are stable. HEENT: On physical exam of his head, his pupils are equal and reactive to light. He has intact extraocular muscles. He has significant edema of the left periorbital soft tissues and 2 transverse lacerations of the inferior eyelid, which are approximately 3 cm in length down to the orbicularis muscle. Additionally, there is a vertically-oriented full-thickness laceration of the right lower lip. Additionally, there is a laceration at the root of the left auricular helix with exposed cartilage, which is approximately 2 cm in length. The patient also has stab wounds to his left neck in zone 2, and multiple stab wounds on his left and right hands. Chest: The patient's chest is clear to auscultation. Abdomen: Soft. Pelvis: Intact. Extremities: The lower extremities have normal distal pulses and are grossly intact. Diagnostic Data: The patient has a CT scan of the face, which does not demonstrate, at least on initial review, any fractures of the face. There is some fluid in the right frontal sinus and also some edematous-looking mucosa in the right maxillary sinus. Assessment and Plan: This is a 45-year-old man with no significant past medical history, who was assaulted the night previously with an unknown weapon, appears that he was assaulted by multiple stab wounds. The patient has an injury to his left neck, and will be going to the operating room emergently with Trauma Surgery for exploration of his left neck. During that time, we will repair his lacerations to his lower eyelid, his lip, and to his ear. The patient was consented for the aforementioned procedures, and appeared to understand the risks of scarring and possible infection that are associated with closing these dirty wounds. Dr. [NAME] is aware of this plan and agrees.

3 Date of Consultation: [DATE] Service Provided: Inpatient Consultation I agree with the inpatient house officer's consultation note handwritten for the Neurosurgery Service by Dr. [NAME] as well as the Trauma Service history and physical examination, and Plastic Surgery Service consultation note in regards to the patient's chief complaint, present illness, allergies, habits, medications, review of systems, past medical history, past surgical history, family history, social history, vital signs, and examination. I have interviewed and examined the patient, reviewed the hospital chart and the neuroimaging, and my dictation follows. History of Present Illness: Briefly, the patient is a young Hispanic man reportedly involved in an assault which involved multiple stab wounds with a knife who was initially evaluated by Trauma and Plastic Surgery and then taken emergently for neck exploration to the operating room, and Neurosurgery was consulted intraoperatively, and one of the scalp lacerations was found to have an underlying temporal bone fracture. We did not have an opportunity to examine the patient prior to the operation. Past Medical History: Reportedly negative. Past Surgical History: Reportedly negative. Medications: None. Allergies: No known drug allergies. Physical Examination Vital Signs: Temperature 36.8, pulse 102, respirations 16, BP 110/72, and 100% saturated on controlled ventilation under anesthesia. Intraoperatively, the patient was found to have a small laceration over his left ear as well as 2 additional lacerations near his vertex just left to midline. These lacerations were of the same shape and size as the lacerations that were present on his neck and his torso suggesting that they were potentially caused by the same instrument. Intraoperatively, the left temporal laceration was explored and found to extend all the way down to the bone which was fractured. Review of the CT scan of the head shows some fracture fragments that were firmly following a convex line consistent with epidural placement restricted by dura. Intraoperatively, there were no signs of CSF or brain extravasation noted. We therefore cleaned the wound out carefully and closed it primarily. Postoperatively, the patient was alert and oriented x3, followed 3-step commands without difficulty, was GCS 15. His cranial examination was as described above. In addition, he had no Battle or Raccoon sign. He had no otorrhea, otorrhagia, rhinorrhea, or rhinorrhagia. His tympanic membranes were clear. His cranial nerves 2 through 12 were serially tested and found to be intact. Muscle strength is 5/5 in all muscle groups tested in all 4 extremities. He had no dysmetria or dysdiadochokinesis on finger-nose and finger-nose-finger testing bilaterally. Reflexes were 2+ and symmetric at biceps, triceps, brachioradialis, and patella with bilateral flexor plantar responses. No evidence of clonus. Dermatomal sensation is intact and symmetric in all dermatomes, tested in all 4 extremities. Joint position sense is normal and intact bilaterally. Diagnostic Data: CT scan is as outlined above. Laboratory Data: Laboratory showed negative tox screen, sodium 141, INR 1.0. Impression: A young Hispanic man with an open head injury, most likely from some sort of stabbing implement

4 leading to an open temporal bone fracture with no evidence of CT of intradural or intraparenchymal brain penetration and no evidence at surgical exploration of CSF or brain. This has been closed primarily after careful washout. We would recommend continuing him on IV antibiotics for a minimum of 48 hours followed by a 7- to 10-day course of p.o. antibiotics. We recommend repeating a CT scan of the head in 12 hours to rule out blossoming of underlying contusion. We would not put him on prophylactic anticonvulsants but would consider treating him Dilantin if he developed a seizure. We would watch the sodium and coags carefully, and we will follow along with you. We would continue the cervical collar until his neck can be cleared clinically.

5 Referring Physician: [NAME] Date of Consultation: [DATE] Service Provided: Orthopedic Hand Consultation History of Present Illness: This is a 44-year-old male who was out drinking last night. He was apparently assaulted by unknown assailant. He cannot remember much of the incident, but he remembers being attacked and he had been struck in the face several times and then he was trying to defend himself with hands. He had multiple lacerations to his face, neck, and bilateral hands. He slept off after the attack, after the fight and was seen by his friends who thought he should go to the hospital and seek medical attention for these injuries. Upon seeing the patient's neck injury, the trauma team immediately came to the operating room for open exploration of his neck injury, as it was a zone II injury. Intraoperatively, they consulted orthopedics for evaluation of the patient's hand injuries as well for both closure and wound exploration. Past Medical History: None. Past Surgical History: None. Medications: None. Allergies: None. Review of Systems: The patient is currently intubated and sedated, and we cannot obtain review of systems. Physical Examination Vital Signs: Temperature is 36.8, pulse is 102, respiratory rate 16, and blood pressure is 110/72. He is saturating 100% on room air. General: The patient is intubated and sedated. He is not able to follow commands. Extremities: Examination of the patient's left hand reveals multiple lacerations to the dorsal and volar aspect of his hand. I explained the wounds reveal that to greatest extent, the one of them is about a centimeter length. They do appear superficial, none of them are deep. There is no exposed tendon or bone. He has brisk cap refill in all digits and examination of the patient's right hand reveals he has only several small lacerations that also appear superficial with the greatest being about 2 cm in its greatest extent. There is no exposed tendon or bone either. He has brisk cap refill in all digits as well. Examination after the patient is extubated and off sedation reveals that he has full range of motion in bilateral hands with sensation intact to light touch in all digits. Brisk cap refill in all digits and he has full function of his AIN, PIN, median, radial, and ulnar nerves. He has full function of both the flexor digitorum superficialis, flexor digitorum profundus, and extensor tendons of all fingers. He also has full function of his FPL, EPL, and EIP. There appears to be no evidence of tendon injury to bilateral hands. This is correlated with intraoperative findings as well. Diagnostic Data: Imaging: Plain film of the patient's left hand are negative for fracture dislocation. Assessment and Plan: This is a 44-year-old male who is status post assault with unknown with bilateral multiple hand lacerations, the left side being worse than the right. However, all these appear superficial in nature. There is no evidence of fracture, nerve, or tendon deficit. I also noted evidence of arterial deficit. Due to the simple nature of these lacerations, we recommended delayed primary closure in the operating room and treating the patient with IV Ancef. After irrigation and debridement of the wounds, they do not appear grossly contaminated. He can be treated for 24 hours with antibiotics for wound prophylaxis and we can observe him to make sure that he does not develop any signs of infection due to his delayed closure. However, does not appear

6 to be any contraindication to closure at this time and also does not appear to be any need for prolonged orthopedic followup, as these are mainly superficial wounds. He will need suture removal in about 7-10 days pending clearance of these wounds and soft dressing will be applied sterilely after this procedure. We will continue to follow the patient on an inpatient basis and assess his progress and possibly we need to perform further surgeries if any of these superficial lacerations develop into infections. However at this point in time, this does not appear to be a case.

7 Date of Operation: [DATE] Preoperative Diagnosis(es): Multiple lacerations to the scalp, face, lower lid, and right lower lip involving the skin; vermilion border, the dry vermilion, and left ear, root of the helix with exposed cartilage. Postoperative Diagnosis(es): Multiple lacerations to the scalp, face, lower lid, and right lower lip involving the skin; vermilion border, the dry vermilion, and left ear, root of the helix with exposed cartilage. Operation Performed: Repair of right lower lip vermilion border and skin and dry mucosa lip laceration (2 cm) with complex repair; repair of left lower lid laceration, simple repair, 6 cm total; repair of left cheek, 2 cm laceration with intermediate repair; repair of left root of the helix ear laceration, 2 cm with complex repair involving cartilage; and repair of total 3 cm of scalp laceration with simple repair with staples. Surgeon(s): [NAME]; [NAME]. Anesthesia: General endotracheal anesthesia. Estimated Blood Loss: Less than 10 cc. Drains: None. Complications: None. Findings: There were multiple lacerations that were repaired. The right lower lip laceration, which involved the skin, vermillion border, and the dry mucosa was repaired in layers as it involved the mucosa and the orbicularis oris muscle. This was closed with 4-0 Monocryl suture in the muscle layer followed by 5-0 chromic sutures in the vermilion and 5-0 fast-absorbing suture in the skin layer. The left lower lid lacerations were in total 6 cm and they were repaired in a simple manner with 5-0 fast-absorbing chromic suture. The left cheek laceration was deep and it was 2 cm in length, and it was closed in layers with 4-0 Monocryl and 5-0 fast-absorbing suture in an intermediate repair. The left ear laceration involved the root of the helix and involved the exposed cartilage, and the cartilage had to be tucked in, and closure took place over the cartilage in layers with 4-0 Monocryl sutures in the subdermal layer and 5-0 fast-absorbing suture in the skin layer, totaling 2 cm. Finally, there were 3 lacerations to the scalp, totaling 3 cm total, and they were all closed with staples in the simple manner. Indications: The patient is a trauma patient, who was under the influence of alcohol and suffered a stab wound to the neck, face, and scalp earlier today. He was taken into the operating room urgently by the trauma service, and we were consulted for multiple lacerations involving the scalp, the left cheek, right lower lip involving the vermilion border, and the left root of the helix of the ear. He will require multiple laceration repairs, and we have discussed this with the patient including the benefits and risks such as infection, bleeding, dehiscence, scarring, asymmetry, possible nerve damage, need for revision, reoperation in the future, and poor cosmetic outcome. He understands and is willing to proceed. In addition, we have discussed possible blood clots in the veins, pulmonary embolus, heart attack, stroke, or death. He understands and is willing to proceed, and informed consent was obtained today. Procedure in Detail: The patient was in the operating room upon arrival since multiple teams were treating this patient. We started the repair of the right lower lip, which involved the vermilion border, totaling 2 cm by closure of the orbicularis oris muscle with 4-0 Monocryl sutures in an interrupted fashion followed by closure of the dry mucosa with 4-0 chromic sutures in an interrupted fashion, and closure of the vermilion border and the skin of the lower lip with 5-0 fast-absorbing suture. All these lacerations were washed out prior to closure. The second set of laceration that we repair where the left lower lid lacerations involving a 4 cm and a 2 cm open wounds, which were closed in a simple repair with 5-0 fast-absorbing suture in a continuous manner. This totaled 6 cm. Next, we closed the left cheek deep wound, which required intermediate repair, totalling 2 cm with 4-0 Monocryl sutures in the subdermal layer and 5-0 fast-absorbing suture on the skin level. The left ear

8 laceration involved the root of the helix and involved the cartilage, which was displaced. The cartilage had to be washed out and placed back into its position, tucked underneath the subdermal sutures with 4-0 Monocryl followed by closure of the skin with 5-0 fast-absorbing suture in an interrupted fashion. This totaled 2 cm. Finally, there were 3 separate scalp lacerations, approximately 1 cm each, which were reapproximated in a simple closure with staples. The patient was then left in the operating room for the remainder of the trauma team and consulting teams to finish their examination and procedures. He tolerated the procedure well and there were no complications.

9 Date of Operation: [DATE] Preoperative Diagnosis(es): Zone II penetrating injury. Postoperative Diagnosis(es): Zone II penetrating injury. Procedure Performed: Neck exploration. Surgeons: [NAME]; [NAME] Anesthesia: General. Findings: The tract of the ( ) knife had passed left lateral to the larynx, and there was no evidence of penetration to the carotid sheath. Estimated Blood Loss: Nil. Complications: None. Condition: Stable. Procedure in Detail: The patient was brought to the operating theater and placed under general endotracheal anesthesia in the supine position. The area of the lower mandible and neck were prepped and draped in sterile fashion. The knife incision was extended approximately 1.5 cm medial and lateral to allow for exposure. The knife had already penetrated the platysma. This was freed further medial and lateral to expose the underlying fascial covering enveloping the thyroid cartilage. We followed the trajectory of the knife deep and posterior. It appeared to pass well lateral to the larynx and to the surrounding subcutaneous tissue. The end point of the tract was easily visualized. The natural fibers were intact overlying the carotid sheath, and this in combination with the preoperative CT angio that showed no evidence of vascular involvement made us believe that there was no discernible injury. The wound bed was then copiously irrigated. The platysmal fibers were reapproximated using 3-0 Vicryl, the overlying skin was approximated using 4-0 Monocryl, and covered with Dermabond. We then deferred further care to Plastics, Orthopedics, and Ophthalmology teams that came in to address the patient's other issues.

10 Date of Consultation: [DATE] Attending Trauma Physician: [NAME] Reason for Consultation: Right temporal bone fracture. History of Present Illness: This is a 29-year-old male status post assault with questionable mechanism with positive loss of consciousness presented to the ER with GCS 15. Neurosurgery is being consulted for right temporal bone fracture and head laceration. Past Medical History: None. Past Surgical History: None. Medications: None. Allergies: No known drug allergies. Physical Examination Vital Signs: Temperature is 36.8, blood pressure 110/72, heart rate 102, respirations 16, and O2 saturation 100% on room air. General: The patient is in no apparent distress. Alert and oriented x3. Moving all extremities. HEENT: The head shows 2 incisions superior to hairline; one is a stellate lesion about 4 cm, and the other one is just lateral to about 2 cm in addition to an anterior auricular laceration about 2 cm deep, extends to temporalis muscle. Right pupil is 4 mm to 2 mm and is reactive; left pupil is 4 mm and minimally reactive, and there is some positive ecchymoses around that eye. Extraocular movements are intact. Ears: External auditory canals are clear. Neurologic: Cranial nerves II through XII are intact. Strength 5/5 for lateral upper and lower extremities, extensor flexors. Sensation to light touch is intact over bilateral upper and lower extremities. The reflexes are 2+ bilateral patellar and Achilles. Diagnostic Data: INR 1.0. Tox screen is negative. Sodium is 141, creatinine 1.0. ETOH is 173. CBC is pending at the time of evaluation. Radiologic studies: CT of the head showed a left temporal bone facture of the squamous portion with about 2 to 4 mm depression, gross contusion and edema related to the fracture. Assessment and Plan: This is a patient with left squamous temporal bone fracture, plan is for irrigation and exploration of the head lacerations while the patient is in the operating room for treatment of other injuries. Dr. [NAME] from Neurosurgery was allowed to examine the patient and document further recommendations.

11 Date of Operation: [DATE] Surgeon(s): [NAME]; [NAME]. Procedure in Detail: Briefly, this is a young gentleman who was assaulted last night, while intoxicated, with a sharp object, sustaining multiple stab wounds to various parts of his body including a left temporal, open, partially depressed, partial-thickness skull fracture without damage to the underlying dura. We were then consulted by Trauma regarding management. The patient was already in operating room with the orthopedic and ophthalmology services with Trauma having finished an emergent neck exploration when the left temporal wound was explored by myself. The area over his left temporal region was shaved revealing an open 3-cm laceration. The area was then prepped and draped in the usual sterile fashion. The laceration was slightly extended using a #15. A ( ) was inserted. Copious irrigation was applied. The bipolar cautery was used to coagulate the superficial temporal artery. Further copious irrigation was applied. Bovie cautery was used to cauterize the edges of the wounds further. After no visible fragments could be identified, the wound was closed with a 3-0 nylon suture in a running fashion. The wound was dressed with a 4 x 4 and tape.