ed case discussion - trauma
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ED Case Discussion - TraumaPresented by: Hakimah Khani Binti SuhaimiSupervised by: Dr Farina (ED Sungai Buloh)
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Chief Complaint
• Mr. AZ, a 21 year-old Malay gentleman was brought to the ED on the 18th October due to an MVA.
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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.
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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
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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.
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Past Medical History
Nil
Drugs & AllergiesNil
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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
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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 %
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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
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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
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Impression
• Open fracture left radius and closed fracture of left ulna
• Bilateral lung contusion• Possible skull fracture /
intracranial bleed
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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
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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
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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
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- CXR: bilateral lungs contusion, no rib fracture, no pneumothorax, no flial segment
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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
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Left Radius & Ulnar X-Ray:- fracture of right radial
styloid
Mx: Above-elbow backslab of right upper limb
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- CT cervical Right pedicle and transverse foramen fracture. In the absence of associated soft tissue injury, these are probably old fracture
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- Pelvic X-RayNo abnormalities detected.
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- 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
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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
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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
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Disposition
• Refer to orthopaedics & surgical team once patient is hemodynamically stable.