Secondary survey

Completed by: Dr. Eleanor Vance Patient History Mechanism Patient involved in a high-speed motorcycle accident. Impact occurred on the left side of the body after the motorcycle collided with a stationary vehicle. Patient was thrown from the motorcycle and landed on the road surface. Injuries Left open femur fracture, left tibial plateau fracture, multiple rib fractures (left side), closed head injury with suspected concussion, and abrasions to the left upper extremity. Past Medical History Patient has a history of hypertension, managed with medication. No prior surgeries. Patient’s normal medications Lisinopril 20mg daily. Social History Lives with another Lives with his wife. Known drug allergies - Penicillin: Rash Tetanus Status Up To Date Open fracture YES Antibiotics administered Cefazolin 2g IV administered at 14:00. Photo taken with consent YES Pelvic ring injury? YES Checklist completed YES (**please mark as appropriate**) Secondary Survey Detail Head - Minor scalp laceration, no obvious skull fractures. GCS 14 (E4, V4, M6). Pupils equal and reactive to light. Neck - No step-offs or deformities. Tenderness to palpation in the cervical region. Full range of motion. Chest - Multiple rib fractures noted on palpation and inspection. Bilateral equal air entry. Abdo - Soft, non-tender abdomen. No guarding or rigidity. Pelvis - Pelvis stable to palpation. No crepitus. Back - No obvious deformities or bruising. Limbs - Left open femur fracture with significant deformity. Left tibial plateau fracture. Abrasions to the left upper extremity. Neurovascularly intact in all limbs. Neurology - GCS 14. Cranial nerves II-XII intact. Motor strength 5/5 in all limbs except left lower extremity (unable to assess due to fracture). Sensory intact to light touch and pinprick in all limbs. Reflexes 2+ and symmetrical. Muscle Group (Power 0-5) Right Left Shoulder abduction 5 5 Shoulder adduction 5 5 Elbow flexion 5 5 Elbow extension 5 5 Wrist flexion 5 5 Wrist extension 5 5 Hip flexion 5 Unable to assess Hip extension 5 Unable to assess Knee flexion 5 Unable to assess Knee extension 5 Unable to assess Ankle flexion 5 Unable to assess Ankle dorsiflexion 5 Unable to assess Reflexes Right Left Biceps 2+ 2+ Triceps 2+ 2+ Supinator 2+ 2+ Knee 2+ 2+ Ankle 2+ 2+ Plantar Normal Normal Perianal/ rectal exam Normal Abnormal Comment Perianal sensation Normal Buttock clench Normal Rectal exam Normal On-Going Care VTE Prophylaxis Prescribed Yes Analgesia Adequate Yes Trauma and Orthopaedic Plan 1 - Stabilize fractures. 2 - Perform open reduction and internal fixation (ORIF) of the femur fracture. 3 - Evaluate and manage tibial plateau fracture. 4 - Monitor for compartment syndrome. 5 - Initiate early mobilisation. Speciality plan Team General Surgery Plan - Monitor for intra-abdominal injuries. - Continue serial abdominal exams. - Consult for further management of rib fractures. Major Trauma Spinal Clearance Checklist for Current Admission Completed by: Dr. Eleanor Vance Spine cleared Yes If yes, Complete Below Precautions ‘X’ Appropriate Details FULL Patient to remain in full spinal precautions until further imaging is completed. Copy Neurosurgical advice and CODE (if applicable) below: Neurosurgery consulted. Advised close neurological monitoring and repeat CT head in 24 hours. No immediate intervention required. Code: 99255