Case Dlscusslon

Haklmab Kbanl 8lntl Subalml

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