ED Case Discussion - TraumaPresented by: Hakimah Khani Binti SuhaimiSupervised by: Dr Farina (ED Sungai Buloh)

Chief Complaint

• Mr. AZ, a 21 year-old Malay gentleman was brought to the ED on the 18th October due to an MVA.

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.

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

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.

Past Medical History

Nil

Drugs & AllergiesNil

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/minEqual 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:4/4E: Adequate exposed and covered

Assessment (Secondary Survey)

GCS:14/15, E4V4M6, Pupil Bilateral Reactive:4/4

Vital Signs:• Pulse rate : 100 bpm• BP : 176/83 mmHg• Respiration rate : 28 /min • Temperature : 37 °C • SPO2 : 100 %

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

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

Impression

• Open fracture left radius and closed fracture of left ulna

• Bilateral lung contusion• Possible skull fracture /

intracranial bleed

Management

Vital signs were reevaluated every 5 minsPut on CBD for strict I/O Chart

Total intake: 2000ml,Total output: 0ml

Patient was kept NBMIM ATT given

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

Management

Wound irrigation over chin, neck and chest was doneRadiological investigations were done• CXR & Pelvic X-Ray • Bilateral Radius & Ulnar X-Ray• CT Brain & Lateral c-spine

- CXR: bilateral lungs contusion, no rib fracture, no pneumothorax, no flial segment

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

Left Radius & Ulnar X-Ray:- fracture of right radial

styloid

Mx: Above-elbow backslab of right upper limb

- CT cervical Right pedicle and transverse foramen fracture. In the absence of associated soft tissue injury, these are probably old fracture

- Pelvic X-RayNo abnormalities detected.

- CT brainNo 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 clearFrontal scalp haematoma~ No ICB/vault fracture

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

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

Disposition

• Refer to orthopaedics & surgical team once patient is hemodynamically stable.