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ED Case Discussion - Trauma
1. ED Case Discussion - Trauma
Presented by: Hakimah Khani Binti
Suhaimi
Supervised by: Dr Farina (ED Sungai
2. Chief Complaint
• Mr. AZ, a 21 year-old Malay
gentleman was brought to the
ED on the 18th October due to
an MVA.
3. History
• Mr. AZ, a 21 year-old Malay gentleman was brought in
by ambulance at around 11pm due to an MVA.
• According to MA, it was a motorbike-vs-car accident.
• Patient was the rider on the motorbike.
• Exact mechanism of injury was unknown.
• Patient was unable to recall anything, not even what he
was driving.
4. History (contd.)
Post-trauma, injuries sustained:
• Left forearm - pain and bleeding
• Upper chest abrasions - pain and bleeding
• No LOC, no headache
• No ENT bleed
• No SOB
• No abdominal pain, no nausea/vomiting
5. History (contd.)
During the process of transfer,
Patient was put on spinal board, and cervical collar was
applied.
He was then managed by resusc. team in red zone.
7. Assessment (Primary Survey)
Upon arrival at ED Resusc. HSB
A: Patient spoke in full sentences, no stridor, airway patent, no obstruction.
Cervical collar was applied to him.
No tracheal shift.
B: Breathing spontaneously; tachypnoeic; RR:28 with SpO2:99% on
HFM 15L/min
Equal chest rise bilaterally. No paradoxical movement.
Upper chest abrasions, no deformities, no open wound.
Reduced air entry at lower zone bilaterally.
C: CRT < 2 sec, PR:100; good pulse volume, warm peripheries. No obvious
active bleeding elsewhere. 2 large bore IV lines were set, attached to 500ml
NS.
D: GCS:14/15, E4V4M6, Pupil Bilateral Reactive:4/4
E: Adequate exposed and covered
9. Assessment (Secondary Survey)
(contd.)
Head-to-toe examination:
• Head: No lacerations/contusion, no ENT bleed, no swollen eyes, presence
of abrasion at chin area
• Neck: Minor abrasion over left shoulder and neck, no distended jugular
veins, no cervical tenderness, no tracheal deviation
• Chest: Negative chest spring, no palpable crepitus over chest wall. Cvs:
Dual rhythm, no murmur
• Abdomen: No bruises, distension, bleeding. Soft, non tender. Normal bowel
sounds
10. Assessment (Secondary Survey)
(contd.)
Head-to-toe examination:
• Pelvic Spring: Negative
• No scrotal hematoma
• Log roll: No evidence of spine tenderness/swelling/deformity
• PR: Normal anal tone, no bleeding
• Lower extremities: No bleeding, swelling or deformity
• Upper extremities: Open wound exposing bone in left forearm and
contused muscle, no active bleeding. Spo2 on all fingers: 98-100%. Limb
immobilization by backslab was done.
• All peripheral pulses are palpable, equal bilaterally, good volume
• Fast Scan at 11pm: No free fluid with sliding sign present
11. Impression
• Open fracture left radius and
closed fracture of left ulna
• Bilateral lung contusion
• Possible skull fracture /
intracranial bleed
12. Management
Vital signs were reevaluated every 5 mins
Put on CBD for strict I/O Chart
Total intake: 2000ml,
Total output: 0ml
Patient was kept NBM
IM ATT given
13. Management
Medications:
-IV Morphine 2.5mg stat and titrated accordingly
-IV Zinacef 1.5mg stat
-IV Flagyl 500mg stat
FBC: Hb:16.3/WBC:11.1(Lymp:38.9/Gran:57.5)HCT:51.4/PLT:345
ABG on HFM: pH:7.397/pCO2:30/pO2:57.8/HCO3:20.1/BE:-5.9
Coagulation profile, RP, GXM 4 pint packed cell were ordered
14. Management
Wound irrigation over chin, neck and chest was done
Radiological investigations were done
• CXR & Pelvic X-Ray
• Bilateral Radius & Ulnar X-Ray
• CT Brain & Lateral c-spine
15. - CXR:
bilateral lungs
contusion,
no rib fracture,
no pneumothorax,
no flial segment
16. Left Radius & Ulnar X-Ray:
- fracture @proximal 1/3rd
and distal end of left
radius
- fracture of midshaft of left
ulna
Mx: Backslab of left upper
limb
17. Left Radius & Ulnar X-Ray:
- fracture of right radial
styloid
Mx: Above-elbow backslab of
right upper limb
18. - CT cervical
Right pedicle and
transverse foramen
fracture. In the absence of
associated soft tissue
injury, these are probably
old fracture
20. - CT brain
No intracranial bleed.
No focal brain parenchymal
lesion.
No midline shift or mass effect.
Normal grey-white matter
differentiation.
Ventricles & CSF-spaces are
normal.
Visualised paranasal sinuses are
clear
Frontal scalp haematoma
~ No ICB/vault fracture
21. Impression
1)open fracture @proximal 1/3rd
and distal end of left radius and
frcature of midshaft of left ulna
2)closed fracture of right radial
styloid
3)bilateral lung contusion
22. Progress
@ 1.30am
• In spite of 2 liter fluids transfused, BP was still unstable;
• dropped to 87/46mmHg, RR 32bpm, PR 101bpm
~ Hypovolemic Shock Class III
• resuscitated with IV 1 pint EO blood 125/96mmHg
23. Disposition
• Refer to orthopaedics &
surgical team once patient is
hemodynamically stable.
Notas do Editor
In addition to that, it was believed that he was only one casualty since the driver of the car just went away / vanishedUnsure velocity, ejection, alone?, ejection?, death?
No other significant complaints
AMPLE history – allergy, medications / drugs, past medical hx, last meal, event
Unable to percuss and do chest rise on upper chest.
BP slightly high – prolly because the sympathetic response following trauma
Unable to percuss and do chest rise on upper chest.
Possible skull fracture as supported by history of retrograde amnesia, abrasion over the chin, GCS!
Simultaneously done along with the assessment
Cefuroxime – antibiotic cover – open fracture
Adjunct to the impression upon 1 & 2 survey
oedema and blood collecting in alveolar spaces and loss of normal lung structure & functionobvious signs of chest wall trauma such as bruisingCrackles may be heard on auscultation but are rarely heard in the emergency room and are non-specificno specific therapy, close monitoring is required and supplemental oxygen should be administered. adequate and appropriate analgesiausually resolve in 3 to 5 days
Unable to percuss and do chest rise on upper chest.
Unable to percuss and do chest rise on upper chest.
Unable to percuss and do chest rise on upper chest.
Unable to percuss and do chest rise on upper chest.
Unable to percuss and do chest rise on upper chest.