What is the emergency room workup for a male who was bucked off a horse?

Emergency Room Workup for a Male Bucked Off a Horse

The emergency room workup for a male bucked off a horse should prioritize assessment for traumatic injuries to the spine, head, chest, and abdomen, with immediate cervical spine stabilization and ATLS protocol implementation.

Initial Assessment and Stabilization

Primary Survey (ABCDE)

• Airway: Ensure patency while maintaining cervical spine immobilization
• Breathing: Assess respiratory rate, effort, and oxygen saturation
• Circulation: Check pulse, blood pressure, and assess for hemorrhage
  • Classify blood loss severity using ATLS classification 1
  • Look for signs of shock (tachycardia, hypotension, decreased pulse pressure)
• Disability: Rapid neurological assessment (GCS, pupillary response, limb movement)
• Exposure: Complete examination for injuries while preventing hypothermia

Immediate Interventions

1. Cervical spine immobilization until cleared clinically or radiographically 1
2. Supplemental oxygen if hypoxemia or respiratory distress present
3. IV access with two large-bore (16-18G) peripheral lines
4. Fluid resuscitation for signs of shock using crystalloids initially
5. Position appropriately:
   • Maintain supine position if shock is present 1
   • If no evidence of spine injury and breathing normally but decreased alertness, recovery position may be considered 1

Diagnostic Workup

Imaging Studies

1. CT scan (preferred if available):

   • Head and cervical spine CT
   • Chest/abdomen/pelvis CT with IV contrast for polytrauma assessment

2. X-rays (if CT unavailable or for specific follow-up):

   • Cervical spine (lateral, AP, odontoid)
   • Chest (AP)
   • Pelvis (AP)
   • Other areas based on clinical findings

3. FAST scan (Focused Assessment with Sonography for Trauma):

   • Assess for free fluid in abdomen, pericardium, and pleural spaces
   • Can be performed rapidly during initial assessment

Laboratory Studies

1. Complete blood count
2. Comprehensive metabolic panel
3. Coagulation studies (PT, PTT, INR)
4. Type and cross-match for potential blood transfusion
5. Arterial blood gas analysis
6. Urinalysis (assess for hematuria suggesting genitourinary trauma)
7. Toxicology screen if indicated (alcohol, drugs)

Specific Injury Considerations

Head Injury Assessment

• Concussion evaluation using standardized tools 1
• Monitor for signs of increasing intracranial pressure
• Assess for retrograde and anterograde amnesia
• Document mental status changes and GCS trends

Spine Injury Assessment

• Maintain spinal precautions until cleared
• Neurological examination of all extremities
• Document sensory levels and motor function
• Assess for priapism, loss of rectal tone, or urinary retention suggesting spinal cord injury

Thoracic Injury Assessment

• Evaluate for pneumothorax, hemothorax, pulmonary contusion
• Assess for rib fractures, flail chest, cardiac contusion
• Monitor for respiratory deterioration

Abdominal Injury Assessment

• Serial abdominal examinations
• Consider DPL (diagnostic peritoneal lavage) if FAST is equivocal and CT unavailable
• Monitor for signs of solid organ injury (liver, spleen) or hollow viscus injury

Extremity Injury Assessment

• Complete musculoskeletal examination
• Document neurovascular status of all extremities
• Assess for fractures, dislocations, and soft tissue injuries

Special Considerations for Equestrian Injuries

• Mechanism of injury: Falls from horses typically involve high-energy transfer and can cause serious injuries even without obvious external trauma
• Common injury patterns: Head injuries, spinal injuries, and thoracoabdominal trauma are particularly common in equestrian accidents 1
• Height of fall: Falls from greater than 6 meters (20 feet) are associated with major injuries 1
• Crush injuries: Assess for injuries from being stepped on or rolled over by the horse

Disposition and Monitoring

• Trauma team activation for moderate to severe injuries
• ICU admission for patients with significant injuries, abnormal vital signs, or requiring close monitoring
• Surgical consultation for patients with injuries requiring operative management
• Serial assessments to monitor for deterioration or delayed presentation of injuries
• Pediatric considerations: Children require specialized assessment and may need transfer to a pediatric trauma center 1

Pitfalls and Caveats

• Beware of occult injuries: Internal injuries may not be immediately apparent despite significant mechanism
• Don't be falsely reassured by normal initial vital signs, as young patients can compensate well before sudden decompensation
• Maintain high suspicion for cervical spine injuries even with normal neurological examination
• Consider non-accidental trauma in appropriate contexts, especially with inconsistent history
• Avoid hyperventilation in head-injured patients as it can worsen outcomes 1

By following this systematic approach, emergency physicians can effectively evaluate and manage patients who have been bucked off horses, ensuring that potentially life-threatening injuries are identified and treated promptly.