ED Case Discussion - Trauma

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 & Allergies

Nil
 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
 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 mins
Put on CBD for strict I/O Chart
Total intake: 2000ml,
Total output: 0ml
Patient was kept NBM
IM 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 done
Radiological 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-Ray
No
abnormalities
detected.
- 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
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