Cblet Complalnt W Mr. AZ, a 21 year-olo Malay gentleman was brougbt to tbe LD on tbe 18 tb October oue to an MvA. Hlstory W Mr. AZ, a 21 year-olo Malay gentleman was brougbt ln by ambulance at arouno 11pm oue to an MvA. W Accorolng to MA, lt was a motorblke-vs-car accloent. W Patlent was tbe rloer on tbe motorblke. W Lact mecbanlsm ot lnjury was unknown. W Patlent was unable to recall anytblng, not even wbat be was orlvlng. Hlstory (conto.) Post-trauma, lnjurles sustalneo: W Left forearn - pain and bIeeding W Upper chest abrasions - pain and bIeeding W o LOC, no beaoacbe W o L% bleeo W o SO8 W o aboomlnal paln, no nausea/vomltlng hks1 Slide 4 hks1 Dr Farina: Can't be LOC. eventhough that was the history given by the NA. because the patient showed symptom of retrograde amnesia. there is a possible period of LOC before the ambulance arrived. :) hakimah k. suhaimi, 11/2/2011 Hlstory (conto.) Durlng tbe transter process, Patlent was put on splnal boaro, ano cervlcal collar was applleo. He was tben manageo by resusc. team ln reo zone. Past Meolcal Hlstory ll Drugs & Allergles ll Assessment (Prlmary Survey) Upon arrlval at LD Resusc. HS8 A: Patlent spoke ln tull sentences, no strloor, alrway patent, no obstructlon. Cervlcal collar was applleo to blm. o tracbeal sbltt. 8: 8reatblng spontaneously, tachypnoeic, RR:28 wltb SpO2:99 on HFM 15L/mln Lqual cbest rlse bllaterally. o paraoolcal movement. Upper cbest abraslons, no oetormltles, no open wouno. Reouceo alr entry at lower zone bllaterally. C: CR% 2 sec, PR:100, gooo pulse volume, warm perlpberles. o obvlous actlve bleeolng elsewbere. 2 large bore |v llnes were set, attacbeo to 500ml S. D: GCS:14/15, L4v4M6, Pupll 8llateral Reactlve:4/4 L: Aoequate eposeo ano covereo hks2 Slide 7 hks2 after the primary survey, it should be followed by "Adjuncts to primary survey". Which include chest Xray, fast scan, ABC. adjunct ni buat bedside. yg lain mcm limb Xray, tak bedside, buat dekat Xray room hakimah k. suhaimi, 11/2/2011 Assessment (Seconoary Survey) GCS:14/15, L4v4M6, Pupll 8llateral Reactlve:4/4 vltal Slgns: W Pulse rate : 100 bpm W 8P : 176/83 mmHg W Resplratlon rate : 28 /mln W %emperature : 37 C W SPO2 : 100 Assessment (Seconoary Survey) (conto.) Heao-to-toe eamlnatlon: W Heao: o laceratlons/contuslon, no L% bleeo, no swollen eyes, presence ot abraslon at cbln area W eck: Mlnor abraslon over lett sbouloer ano neck, no olstenoeo jugular velns, no cervlcal tenoerness, no tracbeal oevlatlon W Cbest: egatlve cbest sprlng, no palpable crepltus over cbest wall. Cvs: Dual rbytbm, no murmur W Aboomen: o brulses, olstenslon, bleeolng. Sott, non tenoer. ormal bowel sounos Assessment (Seconoary Survey) (conto.) Heao-to-toe eamlnatlon: W Pelvlc Sprlng: egatlve W o scrotal bematoma W Log roll: o evloence ot splne tenoerness/swelllng/oetormlty W PR: ormal anal tone, no bleeolng W Lower etremltles: o bleeolng, swelllng or oetormlty W Upper etremltles: pen wound exposing bone in Ieft forearn and contused nuscIe, no actlve bleeolng. Spo2 on all tlngers: 98-100. Llmb lmmoblllzatlon by backslab was oone. W All perlpberal pulses are palpable, equal bllaterally, gooo volume W Fast Scan at 11pm: o tree tlulo wltb sllolng slgn present hks3 Slide 10 hks3 should be in the "adjuncts to primary survey" hakimah k. suhaimi, 11/2/2011 |mpresslon W Open tracture lett raolus ano closeo tracture ot lett ulna W 8llateral lung contuslon W Posslble skull tracture / lntracranlal bleeo Management vltal slgns were reevaluateo every 5 mlns Put on C8D tor strlct |/O Cbart %otal lntake: 2000ml, %otal output: 0ml Patlent was kept 8M |MA%% glven Management Meolcatlons: -|v Morpblne 2.5mg stat ano tltrateo accorolngly -|v Zlnacet 1.5mg stat -|v Flagyl 500mg stat F8C: Hb:16.3/W8C:11.1(Lymp:38.9/Gran:57.5)HC%:51.4/PL%:345 A8G on HFM: pH:7.397/pCO2:30/pO2:57.8/HCO3:20.1/8L:-5.9 Coagulatlon protlle, RP, GXM 4 plnt packeo cell were oroereo Management Wouno lrrlgatlon over cbln, neck ano cbest was oone Raolologlcal lnvestlgatlons were oone W CXR & Pelvlc X-Ray W 8llateral Raolus & Ulnar X-Ray W C% 8raln & Lateral c-splne - CXR: biIateraI Iungs contusion, no rlb tracture, no pneumotbora, no tllal segment hksS Slide 1S hksS Dr Farina: must see many many normal CXRs, then only we can appreciate abnormal CXR hakimah k. suhaimi, 11/2/2011 Lett Raolus & Ulnar X-Ray: - tracture @prolmal 1/3ro ano olstal eno ot lett raolus - tracture ot mlosbatt ot lett ulna M: 8ackslab ot lett upper llmb Lett Raolus & Ulnar X-Ray: - tracture ot rlgbt raolal stylolo M: Above-elbow backslab ot rlgbt upper llmb - C% cervlcal Rlgbt peolcle ano transverse toramen tracture. |n tbe absence ot assoclateo sott tlssue lnjury, tbese are probably olo tracture - Pelvlc X-Ray o abnormalltles oetecteo. - C% braln o lntracranlal bleeo. o tocal braln parencbymal leslon. o mlollne sbltt or mass ettect. ormal grey-wblte matter oltterentlatlon. ventrlcles & CSF-spaces are normal. vlsuallseo paranasal slnuses are clear Frontal scalp baematoma ~ o lCB/vauIt fracture |mpresslon 1)open tracture @prolmal 1/3ro ano olstal eno ot lett raolus ano trcature ot mlosbatt ot lett ulna 2)closeo tracture ot rlgbt raolal stylolo 3)bllateral lung contuslon hks3 Slide 21 hks3 requires oxygenation! hakimah k. suhaimi, 11/3/2011 Progress @ 1.30am W |n splte ot 2 llter tlulos transtuseo, 8P was stlll unstable, W oroppeo to 87/46mmHg, RR 32bpm, PR 101bpm ~ ypovoIenic 5hock CIass lll W resuscltateo wltb |v 1 plnt LO blooo 125/96mmHg hks6 hks7 Slide 22 hks6 Dr Farina: From yr assessment, yg problem is only the limb fracture. but the circulation ie the CRT, pulse volume, everything ok kan? active bleeding pun tkde kan? so mana dtg tetibe shock? and betulkah shock? dan if yes, which type? betul ke hypovolemicccc? Student: Spinal shock? Dr Farina: ur wrong when you say spinal shock. sebab yang involve autonomic nervous sys is neurogenic shock, not spinal Dr Farina: is 2 liters of fluid banyak ke sikit? Student: Regular? because 2 litres can only maintain in the plasma for 2 hours je (i think) Dr Farina: 2 liters sebenarnya sikit. because we tak tau berapa banyak blood loss yang patient tu ada. and 2 liters tu patutnya within minutes dah kena transfused.. hakimah k. suhaimi, 11/3/2011 hks7 Student: EO blood tu apa? Student: Erythrocyte only Dr Farina: A big NO. it's emergency O blood. !n ED, they stock up the blood. ada 10 pints altogether and we use that quite often :) preferably, we want O ve. sebab? Student: tak nak ada rhesus incompatibility Dr Farina: in whom do we fear to give O+? in ladies childbearing kalau in men or old ladies tk risau sgt dia takkan ada problem during the first introduction of rhesus +ve tu. tp bila? Student: bila labour Dr Farina: what is the condition called? Dlsposltlon W Reter to ortbopaeolcs & surglcal team once patlent ls bemooynamlcally stable. hks8 Slide 23 hks8 We don't refer once the patient is hemodynamically stable. tapi immediately! hakimah k. suhaimi, 11/3/2011