1

Topic – Trauma and other stations

Glasgow Coma Scale

Response Scale Score
Spontaneously 4 Points
EYE OPENING To verbal command, speech, or shout. 3 points'
RESPONSE (E4)
To pain (Not applied to face) 2 points
No response 1 point
 
Oriented to time, place and person or (Oriented x
3) 5 points
Confused conversation, but able to answer
questions 4 points
VERBAL
Inappropriate response or speech, words
RESPONSE (V5)
discernible 3 points
Incomprehensive sound or sound 2 points
No Verbal response 1 point
 

Obeys commands for movement 6 points

Moves to localised pain or
Purposeful movement to painful stimulus or
Localises pain
5 points
Flexion withdrawal from pain or
MOTOR Normal flexion 4 points
RESPONSE (M6)
Abnormal (spastic) flexion, decorticate posture 3 points
Abnormal extension or
Extensor(Rigid) response or
Decerebate posture or
Extension to pain 2 points
No Motor response or
Flaccid 1 point

Minor Brain Injury = 13-15 points;

Moderate Brain Injury = 9-12 points;
Severe Brain Injury = 3-8 points
 2

Meningitis examination
25 year old man Mr Edwards came to the hospital c/o headache.
Assess the patient and tell your diagnosis and management to the examiner

Differentials for headache

Sinusitis – Headache gets worse on leaning forward
Glaucoma – Pain behind the eyes, Halos around the light
Refractory error – Do you have problem in vision while reading or driving
Cluster headache – Headache coming in clusters, watering in the eyes.
GCA – Headache on temple area , pain while chewing, vision problem
Migraine – one sided headache
SAH – Occipital headache, Worse headache
Head injury – Trauma
Meningitis – Fever, photophobia, Neck stiffness, contact history
Brain tumour – early morning headache, weakness in limbs,
Stroke – Weakness in limbs, speech problem
Greet the examiner. Go to the patient
Patient is lying down with hands over the eyes ( covering eyes) / or he may be
wearing dark glasses.
Talk to the patient.
Hello Mr Edwards, I am Dr ... one of the junior doctor in the emergency department, I
am here to examine you. Pt - OK
How can I help you ? Pt - I have severe headache doctor.
Dr: I am sorry to hear that. Do you need any pain killers ? Pt : Yes doctor.
{ Or Patient may make incomprehensible sounds only}
Dr – Ok I will you pain killers. Tell the examiner I would like to give pain killers to
my patient. What should I do ? Examiner says – Assume you have given.
 3

Ask patient - do you feel better.

Ask patient why are you covering your eyes
Pt – Doc the lights are too bright I can’t open my eyes.
Dr – Ok don’t worry I will dim the light
Tell the examiner I would like to dim the light what should I do ?
Examiner may say – assume or may tell you to dim the light.
Tell the patient – the light is dim now – can you please open your eyes – can you
please put your hand down ( remove hand from over the yes) ( If patient is wearing
dark glasses – ask him to remove the glasses, if he is making incomprehensible
sounds you remove his glasses).
Take history if the patient is talking. [ If the patient is making incomprehensible
sounds – then you cannot take history]
Dr: How can I help you Mr Edwards ? Pt: I am having Headache doctor.
Dr: Since when ? Pt: Since last few hours.
Dr: How severe is your headache Can you please rate your pain in the scale of one to
ten one being the mildest and 10 being the most severe pain. 8 out of 10. ( SAH)
Dr: Where is the headache ? ( SAH, Migraine) Pt: All over the head,
Dr: Do you have any fever? ( Meningitis)Pt: Yes.
Dr: Do you have vomiting?( Meningitis, SOL) Pt: No
Dr: Do you have any pain in the eye ( glaucoma) ? Pt: No
Dr: Did you have any injury to your head recently ? Pt: No
Dr: Did you feel weakness in any arms or legs ? (SOL) Pt: No
Dr: Did you have headaches like this before ? Pt: No
Dr: Are you taking any medications ? Pt: No
Dr: Are you allergic to anything ? Pt: No
Dr: Did you come into contact with any one with similar symptoms ? Pt: No
Dr: I need to examine you now.
Check the NEWs chart for temperature.
Then do the GCS
( In this station GCS can be anything between 6 to 15. Most of the time it was 9)
Tell the GCS to the examiner
Then check for Meningism signs:-
 4

Neck Stiffness:
 Support patient’s head with your fingers at the occiput and flex the head
gently until chin touches the chest.
 If neck stiffness is present then neck cannot be passively flexed and you will
feel spasm in neck muscles.

Brudzinski’s sign: while trying to touch chin to chest, look at the flexion of knees in
response to neck flexion which indicates +ve Brudzinski’s sign.

Kernig’s Sign
 Flex one of patient’s legs at the hip and knee, with your other hand placed
over the medial hamstrings.
 Use one hand to extend the knee while the hip is maintained in flexion.
 Kernig’s sign is positive when
1) Extension is resisted by spasm in the hamstring.
2) The other limb may flex at the hip and knee.
3) Complains of pain at the back
4) Bends his head


Exposure : - If the GCS is 15 tell the patient – Can you please undress I will
ensure privacy and have a chaperone with me.
If the GCS is low tell the examiner – in real life I will undress him completely – what
shall I do here. Examiner says – assume

Look for rash - The check for rashes all over the exposed area including face neck
back, arms and legs ( you can use the pen torch to look for rashes).
 5

If you find any rashes tell the examiner – I will check whether it is blanching or not.
( If there is no rash – say there is no rash over the exposed areas, however I will check
all over the body for the rashes).
Ideally I will do Neurological examination.
Cover the patient.
Thank the patient.
Tell your diagnosis and management to the examiner

Diagnosis – I think he has meningitis( Reasons for diagnosis – He has

headache, photophobia, Low GCS, Neck stiffness, Kernigs sign and Brudzuski sign
positive and also has rashes ( if there are any rashes).

Management
Investigations
1) Blood – FBC, U&Es, CRP, Blood culture,
2) CT scan of brain
3) Lumbar Puncture

Treatment
4) Admit
5) Inform seniors
6) IV antibiotics ( Ceftriaxone, vancomycin – according to hospital protocol)
Manage infection
7) Isolate the patient
8) Inform Infection Control team.
9) Trace all close contacts and give prophylactic medication. ( Ciprofloxacin or
Rifampicin)
 6

ATLS

Advance Trauma and Life support

It is a guideline to assess and manage the patients who have met with high velocity trauma.
Initial assessment of a patient who have met with a high velocity trauma

Airway patent A – Airway with cervical Airway patent

stabilization and O2
If breathing means has B - Breathing No Breathing
circulation. Then check for
chest injuries
Check for bleeding C - Circulation No circulation
Disability D - Disability Means cardiac arrest
Exposure E - Exposure Do CPR
ATLS BLS / ALS

TRAUMA TEAM:

1. A&E Doctors & Nurses

2. Surgeons
3. Anaesthetists
4. Orthopaedicians

AIM –is to prioritize and to save time of assessment of the trauma victims to
save life.

ATLS is divided into 2 parts:

1. PRIMARY SURVEY:
Look for immediately life threatening and limb threatening injuries in the order of
priority, manage them and stabilize the patient.

2. SECONDARY SURVEY:

Take a detailed history and then do a thorough head to toe examination to look
for other nonlife threatening injuries.
 7

(Done after the primary survey once the patient is stabilized)

(Done after the primary survey once the patient is stabilized)
A) Take a detailed history
B) Thorough head to too examination, looking for delayed life threatening injuries and non life threatening injuries.

PRIMARY SURVEY:
A Airway with Cervical Stabilization
B Breathing With Ventilation
C Circulation with Control of haemorrhage
D Disability
E Exposure

AIRWAY:
If the patient is able to speak in a normal speech there can’t be any obstruction in their
airway.

Cervical Stabilization:
Assume all the major trauma victims to be having neck injury and stabilize their neck to
prevent any cord injury happening, if it is not already injured.
Two ways to stabilize 1 ) Manual inline immobilization, 2) Triple immobilization

Give High flow oxygen

BREATHING:

1. Tension Pneumothorax:
Signs & Symptoms: Breathless, Engorged Neck Veins, Trachea Shifted To Opposite
Slide, Decreased Chest, Wall Movement,
Hyper-Resonance, Absent Breath Sound,
Tachycardia, Hypotension, Hypoxia.

Management:
Emergency Needle Thoracocentest to decompress the chest
Insert wide bore needle in the 2nd intercostal space, mid clavicular line on the affected side
and leave the cannula in situ. Listen for hissing sound of gush of air coming out. Then
reassess.

Definitive Management:
Intercostal chest drain in the 5th intercostal space which is connected to the underwater sealed
bottle.
 8

2) Open Pneumothorax
Signs & Symptoms: Breathlessness, no engorged neck veins or tracheal shift,
decreased chest wall movement, open wound over the chest, hyper-resonance,
diminished breath sounds.

Management
Cover the wound with a bandage which is stuck on three sides only which allows the air to
escape out, but prevents air getting sucked in.

Definitive Management:
Intercostal Chest Drain

3) Massive Heamothorax
Has double problem: Blood Loss and Lung Compression

Signs & Symptoms

Decreased level of consciousness, pallor, cold periphery,
Breathlessness, tracheal shift, collapsed neck veins,
Decreased chest wall movement, bruises, dullness on percussion, absent or diminished breath
sounds.

Management
Resuscitate; Oxygen, IV Access, Blood Testing, IV Fluids, Chest Drain, Thoracotomy and
repairing of all the damages.

4) Cardiac Tamponade
Can die of reduced cardiac output
Signs & Symptoms
Decreased level of consciousness, cold peripheries,
Becks’ triad- engorged neck veins, hypotension, muffled heart sounds.

Management: Oxygen, IV Access, Maintenance fluid, Attach Cardiac Monitor,

Defibrillator should be available
Pericardiocentesis by seniors

3). Flail Chest

Fracture of two or more ribs at two or more sites.
Causes pulmonary contusion causing hypoxia.
Pain – shallow breathing –hypoxia.
May have associated injuries like pneumothorax or heamothorax.
 9

Management
Oxygen, analgesics, fluid resuscitation, strapping the segment, IPPV

CIRCULATION:

External Bleeding:
Direct Pressure Bandage, IV fluids if required and wound repair.

Internal Bleeding
Chest, Abdomen, Pelvis and Thigh

Intra Abdominal Bleeding-

Signs and Symptoms

Distension, bruises, wounds, tenderness, rigidity, guarding, flank dullness, absent or sluggish
bowel sounds.
Management
Resuscitate
Call for surgeons and make arrangements to shift the patient to theatre for urgent laparatomy.

Pelvic Fracture
Signs and symptoms
Bruises, pelvic deformity, blood at the external urethral meatus, scrotal or perineal
heamatoma
Spring test
Spring test can dislodge clot or rupture more pelvic vessels causing more bleeding - so do it
only if necessary to do it.

Management
Resuscitate
Apply pelvic strapping, call for Orthopeadicians for external pelvic fixators and for further
management.

THIGH; fracture of shaft of femur can cause internal bleeding up to about 2 liters on one
side itself.

Signs and Symptoms

LOOK – swelling, bruises, deformity.
FEEL – distal pulses
 10

MOVE- Do not try to move if there is a swelling seen over the thigh also do not try to move
his legs if he had pain on his pelvis( ie –if spring test was positive).

Management
Resuscitate, Thomas splint, call for Orthopeadicians for further management.
Look for swelling or deformity in any other part of the limbs, and if any check distal pulse

DISABILITY :
Check level of consciousness ( GCS )
Also check the pupils
Look for head injury signs – swelling, lacerations or bruise on head and forehead.
Check the sugar

EXPOSURE: expose the patient completely but keep him covered with warm blankets to
prevent hypothermia.

ADJUNCTS IN PRIMARY SURVEY:

1) MONITORS: Cardiac Monitor

2) PRIMARY SERIES OF X RAYS

A) Chest X Ray
B) Pelvic X Ray

3) TUBES
A) Nasogastric tube
B) Urinary catheter
(Urethral catheter if no urethral injury and Supra Public Cystostomy if
Urethral injury)

3 things to assume in a patient met with high velocity trauma

1) Neck injury
2) Hypoxia
3) Hypovolemia
 11

PRIMARY SURVEY ( Initial assessment after trauma)

You are the FY 2 doctor in the A& E department.

Mr Robinson is a 30 year old man fell from 2 meter height onto concrete floor from a
building while painting the building about half an hour ago. He was brought into the
hospital A&E Department.

His pulse is 100/min and BP is 90/40.

Do the systematic assessment for trauma. Stop the assessment at 6th min bell and discuss
the further management with the examiner.

Greet the examiner.

Tell the examiner – I assume I have taken all Universal precautions (gloves, gown and
goggles) and I will call the Trauma team.

Airway

Patient lying down with collar.

Check response. Hello Mr Robinson, I am Dr… one of the junior doctor in the A&E
department. I am here to examine you. Is that OK ?
Patient - OK.
Tell the examiner – Since he is speaking - he is conscious and airway is patent.
His neck is already stabilized with collar. I will give him high flow oxygen.

Mr Robinson – can please tell me what happened?

Pt: I fell from a building while painting.
Dr – Do you have any pain anywhere at all?
Pt: Yes/ No .

Tell the patient about the exposure - Mr Robinson, I need to examine now, for that we
need to undress you by cutting all the clothes. I will ensure privacy and have chaperone
with me. Is that OK ? Pt – OK doctor.
Ask the examiner – what shall I do ? Examiner says – assume he is exposed.

Breathing

Inspection – I will check for Breathlessness,

Neck – I will check for engorged neck veins, tracheal shift.
Chest – Bruises, open wound, flail chest, asymmetry of movement.
Palpation – Expansion is equal
Percussion – I will check for hyper resonance or dullness.
Auscultation- I will check for absent or diminished breath sounds and muffled heart
 12

sounds.

If nothing, I assume the chest is fine.

Circulation

There are no signs of external bleeding

I will check for pallor and cold peripheries.

Pulse and BP (check the monitor, or NEWS chart – mention the reading to the
examiner. If there is no monitor or NEWS chart then ask the examiner for the vital
signs)

Check for internal Bleeding--

Abdomen-: Inspection - bruises, distension, wounds,

Palpation – Tenderness, rigidity, Guarding
Percussion- Flank dullness
Auscultation – Sluggish or absent bowel sounds

If no signs – I assume the abdomen is fine.

Pelvis: Inspection – I will check for bruises, deformity, scrotal or perineal hematoma or
blood at the external urethral meatus.
Then do the spring test - First warn the patient - I will be pressing your hips and if it
hurts please let me know. Gently press on his pelvis either trying to open it or to close it.
If no signs – Pelvis is fine.

In the exam if they keep Pelvic fracture as the diagnosis patient will scream with pain.
Tell the patient - I am sorry to hurt you.

Thigh - Inspection – There are no bruises, swelling and deformity

Palpation – I will check distal pulses.
Movement – Do not check.

If there is no swelling of the thigh – I assume there is no fracture femur both sides.

Disability

Do the GCS. Use the GCS chart on the wall. GCS may be 15.
I will check for head injury signs like swelling laceration and any bruises on head and
forehead. Any bleeding from nose and ears.
Check the pupils – pupils are equal in size and reacting to light.
I will check the sugar

Exposure

I will cover him with warm blankets to prevent hypothermia

I will tell the nurses to arrange for Chest and Pelvic X Rays.
 13

Tubes
I will insert urinary catheter and Nasogastric tube.

Once he is stable I will do secondary survey.

Thank the patient and the Examiner.

At 6th min – stop the assessment if you have completed and discuss further management
with the examiner
Tell you diagnosis and management – Fracture pelvis, or fracture pelvis and intra
abdominal bleeding.
I will send the blood testing (FBC, U/E, Group and X-match 4 units, sugar, ABG,
clotting screen)
I will give him IV Fluids - 2 litres of warm Hartman’s solution. ( One litre fast ( within
10 min) next one litre in the next one hour). – arrange blood transfusion immediately –
may be O negative then cross matched blood.

I will stabilize the pelvis with pelvic strapping and inform the Orthopaedicians for
external pelvic fixator and for further management.

If signs of intra - abdominal bleeding – I think he has intra - abdominal bleeding, I will
resuscitate, inform the surgeons and shift him to the theatre for urgent laparotomy.

If there is swelling of thigh – I can see swelling of thigh, I will check distal pulse, I think
he has fracture femur, I will resuscitate, apply Thomas splint, and inform
Orthopaedicians for further management.

ATLS [Primary and secondary survey]

Question :-
A man was found lying on the pavement. He has been brought into the hospital by the
ambulance.
You are the FY2 doctor in the A& E department. Your Consultant and registrars are busy.
A&E nurse has taken the hand over from the Ambulance who brought him in. Nurse is
with the patient in the resuscitation room. She has checked his vitals and inserted IV
cannula. She has checked his blood sugar which is 5.7 mmols.
Assess the patient and discuss your findings and the management with the examiner.
Greet the examiner and tell him “ I assume I have taken all the universal precautions
Talk to the nurse – Hello I am Dr ..What is your name?
Nurse: I am Sarah Doctor.
Dr: Hello Sarah can you please tell me what happened ?
Nurse : We have a 30 year man Mr….met with trauma was found on the pavement by the
ambulance and they brought him in just now.
Dr: Do you know his vitals.
Nurse: Yes his BP is 130/80 and his pulse is 85.
Dr: OK, I can see on the monitor his O2 is 96 %. (Give O2 - if saturation is low). Resp
Rate – 18/min. Patient is already on collar. Sarah – Can you please call the trauma team.
Talk to the patient
 14

“Hello Mr … , Are you OK” – ( He may make some incomprehensible sounds).

Tell the examiner – since he is making sound his airway is patent.
He is breathing and respiratory rate is 18/min
Dr: Sarah we need to cut all his clothes – do we have scissor ( examiner may say – assume
he is exposed)
Examine for breathing :
He is not breathless, No neck vein engorgement or tracheal shift.
Chest examination :
Inspection –I will check for bruises, open wounds any flail segments on the chest.
Palpation : Expansion is equal.
Percussion : No hyper resonance or dullness.
Auscultation: No absent or diminished breath sounds or muffled heart sounds.
I assume the chest is fine.
Check for external and internal bleeding
No signs of any external bleeding.
Examine the abdomen:
Inspection : No distension, bruises or open wounds.
Palpation – No tenderness and rigidity or guarding.
Percussion – No flank dullness
Auscultation – No absent or sluggish bowel sounds.
I assume the abdomen is fine.
Examine the pelvis:
I will check the pelvis for bruises, deformity and for any blood in the external urethral
meatus.
Do Spring test – if patient did not show signs of tenderness – I assume the pelvis is fine.
Examine the thighs:
There are no swellings or deformities on both the thighs. I assume there is no femur
fracture.
Disability
Dr: Sarah, what is his blood sugar?
Nurse : It is 5.7 mmols doc.
Check conscious level with GCS – patient is responsive to the verbal stimulus. Tell the
score to the examiner.
Check the pupils with torch – both pupils are equal in size and reacting to light.
I will check the head for injuries – There are no swellings or lacerations on the head but I
can see bruise on the left side forehead.
There are no bleeding or CSF leakage in the ears and nose.
Do quick neurological examination.
I can’t do sensory and motor because he is not conscious.
Reflexes are normal in all 4 limbs including plantar reflex.
I will log roll the patient with the help of 3 other people and examine the back for any
injuries, any spinal injuries, I will do per rectal examination.

Dr: Thank you. Can you please send his blood for group and cross match, FBC and U&E.
Can you also ask the radiographer to do chest and pelvic X Rays.
I will insert NG tube and urinary catheter.
Talk to the examiner - I think he has head injury because he has low conscious level and
has bruise on the forehead.
I will inform the seniors immediately and start with IV fluids and arrange CT scan of his
head. Will consider giving Mannitol after consulting seniors.
 15

Patient may need surgery if he has intracranial bleeding. I will inform the Neurosurgeon.

I will do the secondary survey one he is stable.

Since he is not conscious I cannot take history.
( If patient is responding take brief history
What happened, when happened, Any pain anywhere? Any medical conditions, Any
medications, Any allergies? When did you eat or drink last?)
Head to toe examination.
No swelling lacerations on head. Bruise is present on the left side fore head.
Eyes appears fine.
There are no swelling bruises on cheeks or jaws.
I will examine thoroughly for any injuries over neck, chest, abdomen and pelvis again.
There are no swellings or deformities in the upper limbs. Radial pulse is present both sides.
There are no swellings or deformities in the lower limbs. Dorsalis pedis pulse is present
both the sides.
I will remove the collar if there are no signs of neck injury. I will cover the patient.
I will keep monitoring the patient until the trauma team arrives.
Thank you Sarah. Thank the examiner.

Whiplash injury
Information.
This is a soft tissue injury in the back of the neck due excessive movement of
the neck (eg - in Road traffic accidents) which causes stretching of muscles
and ligaments in the back of the neck. There is no bony injury or spinal cord
injury.
Symptoms usually appear after few hours or may the next day. Symptoms are
pain in the back of the neck and stiffness of the neck which usually lasts about
2 to 3 weeks and subsides on their own.
Other symptoms: Headache, Pain in shoulders and arms, dizziness, Blurred
vision, pins and needles in arms, memory loss, irritability.
Treatment – Analgesics, neck exercise and ice compressions. If they do not
subside in 2 to 3 weeks time then - Physiotherapy.
Advise them not to drive until pain and stiffness subsides.
In some people symptoms can lasts for few months.

Neck Injury
Differentials – Whiplash injury, Stable fracture of the cervical vertebra, Radiculopathy
( root compression – causes tingling numbness in hands).
Question
30 year old Mr Morrison met with a road traffic accident 2 hours ago. He came to the
hospital now complaining of pain and stiffness in his neck. Take a brief history and do the
necessary examination and discuss the further management with the patient.
Patient may be sitting on the chair or couch.
 16

History :
Dr: How can I help you ?
Pt : I met with the road accident about 2 hours ago. Now I have pain in my neck.
Dr. I a sorry to hear about the accident. Can you please tell me more about the accident ?
Pt: I was driving my car. Another car hit the back of my car.
Dr: What happened after that ?
Pt: I was fine initially. I went to the office then I started to have pain in my neck.

Dr: Where in the neck you have this pain? –Pt: Back of the neck.
Dr: Since when? Pt: There was no pain immediately after the accident but then I went to
the office I started to have pain - almost one hour now.
Dr: Does the pain go anywhere from the neck ? Pt: No
Dr: Anything else? – My neck is stiff. Since when?- Pt: Since the last one hour.
Dr: Anything else? – Like what doctor?
Dr : Do you have headache? Pt : No Dr Any dizziness ? Pt : No
Dr: Any problem in your vision? Pt : No
Dr: Any tingling or numbness in your hands? – Pt: No
Dr: Any problem in the neck before this accident? – Pt: No

Dr: where there anyone else in the car ? Anyone else had serious injuries?
Pt : No ( sometimes he may say driver was driving the car but he is fine).
Examination :
I need to examine you now. [ patient may be adequately exposed. If not mention about the
exposure. Can you please undress above the waist ? Pt - Ok. Patient may then remove the
shirt]
Inspection of the neck :
Look all around the neck ( front sides and back)
No swelling, no bruise or wounds around the neck. No neck deformity.
Palpation : I’m going to feel the back of your neck over the spine with my thumb. Please
tell me if it hurts. Just say yes or no but do not move your head too much. – Pt: Ok Doctor.
Then check for tenderness over the cervical spine up to about 2nd thoracic vertebra : (there
may or may not be any tenderness over the spine)
Then check for tenderness over both the para-spinal areas : ( Usually there is tenderness
there).
Then do neurological examination. –
Sensory – fine touch (with wisp of cotton) on both the upper limbs.
Then check for pain sensation with neuropin : [No sensory loss].
C4 – top of shoulder, C5 – Outer aspect of upper arm, C6 – outer aspect of hand ( thumb
area), C7 – middle finger, C8 – Little finger, T1 – Medial aspect of elbow.
Check the vibration sensation and Joint position.
Motor – C5- Shoulder abduction and Elbow flexion, C6 - Elbow flexion and wrist
extension, C7 – Elbow extension and wrist flexion and finger extension, C8 – finger
flexion, T1 – Finger abduction ----- No motor deficits.
Check reflexes in upper limbs : Biceps reflex ( C5), Brachioradialis reflex ( C6), Triceps
reflex (C7). --- Normal
No need to do neck X Rays if there is no bony tenderness.
If there is bony tenderness - Tell the examiner I will make him lie down and stabilize his
neck and send him for X rays of his neck. Can I know the X-ray result please ?
( Examiner may say – X Ray – normal )
I will remove his collar and check for neck movements.
 17

Ask the patient - Please turn your head to right, left, up and down and both sides- flexion
movements. Movements are restricted ( whichever direction). Thank you.
Management with the patient : You have a condition what we call us whiplash injury. It
is due to sudden stretching of muscles and ligaments at the back of your neck which
happens due to excessive movements of the neck during the accident. Usually there is
tearing of muscles and ligaments at the back of the neck. But you do not have any serious
problems like fracture or spinal cord injuries.
The symptoms of whiplash injuries – that is pain and stiffness will subside on their own in
about 2 to 3 weeks.
Please take pain killers like Paracetamol and keep doing some neck exercises until then.
Sometimes it can last for months. If it does not subside in 2 to 3 weeks we will arrange
physiotherapy. Is it Ok? Any questions.
Pt: Can you please give me a collar to the neck
Dr: We used to give collar previously but we found out that the collar will only worsen the
stiffness of your neck. So nowadays we do not give collar. It is better that you keep moving
your neck.
Pt; Can I drive doctor?
Dr: It is better not to drive until your pain and stiffness in your neck subsides.
Pt; Why did I get pain in my neck after few hours not immediately?
Dr: This is what usually happens in whiplash injury because it takes some time for the
inflammation ( soreness) to start and then it becomes painful.

Brachial plexus injury

38 year old Mrs Sharon ... had Road Traffic Accident one year ago. She had brachial
plexus injury. She wants to go back to her work. Assess her condition to check whether
she is fit to go back to work. At 6th min bell examiner will ask you questions.

Dr: Hello Mrs Sharon .. I am Dr.... one of the Junior doctor in the ... department. How can I
help you ?
Pt: Doctor I met with a road traffic accident one year ago. Had injury to Brachial plexus on
my right side. I was undergoing physiotherapy for that. I was not working all this time since
the accident. I want to know whether I can go back to work now ?
Dr: First of all I am very sorry to hear about the accident and the injury you had. You said
you had brachial plexus injury – do you know what type of injury was that – were the nerves
cut or was the nerves just got stretched ? Pt: I do not know.
Dr: Were you told that you had any fracture in the neck bones or any disc prolapsed in the
neck? Pt: No /Yes
Dr: Ok. Did you have any wounds over the neck ? Pt: No
Dr: Ok, May I know what is your job ?
Pt: I work as engineer at Royal Air Forse ( RAF). My work involves tightening screws
( rotational movements at wrist)
Dr: Did you have any problem working on computer or any other type of work before you
had this accident ?
Pt: No doctor. I was perfectly fine. I could do all the jobs properly.
Dr: May I know what functions in the hand you could not do after the accident ?
Pt: Doctor I could not do ......
Dr: Have you tried doing those jobs now ?
 18

Pt: Yes, I can do all those now. Can I go back to work ?

Dr: Let me assess you completely and then I will tell you if that is OK with you ? Pt: Ok
Dr: Are you able to write with a pen on paper ? Pt: Yes I can now.
Dr: Are you able to eat food with a spoon? Pt: Yes
Dr: Do you feel hot and cold sensations in your hands ? Pt: Yes
Dr: Do you have any other medical conditions ? Pt: No
Dr: Are you on any medications ? Pt: No

Dr: Mrs Sharon .. I need to examine your neck and hands now Is that OK? Could you please
undress those area. Pt: Yes doctor

Examination
Inspection of neck.
No scars over the neck, No deformity or swellings.

Do the upper limb neurological examination.

Sensory - fine touch and pain.
Check Joint position and vibration
Check power – C 5 – shoulder abduction, C6 – elbow flexion, C7 – elbow extension. C8 –
finger extension, T1 – finger abduction.
Check the grip – ask the patient to hold your 2 fingers tight and you try to pull that out.
Ask the patient to touch his thumb to tips of other fingers in the same hand.
Check the typing action movement of fingers.
Check reflexes

Everything will be normal or there may be weakness.

Dr: Thank you Mrs Sharon ...

Talk to the examiner

I would to talk to the physiotherapist and the Occupational therapist and seniors and take
their opinion about this. We may need to do nerve conduction studies. However, so far with
the information what Mrs Sharon gave me and with the examination findings which were are
normal, I think she is fit to go back to work / she still has weakness – so she is not fit to go
back to work. She may need to continue Physiotherapy.