Emergency Trauma Assessment (Primary Survey Notes)

Patient Information: - John Smith - 45 - Male - 85 kg Date of Examination: 01/11/2024 Reason for Trauma Assessment: Patient presented to the emergency department following a high-speed motor vehicle collision. Mechanism of injury involved a direct impact to the driver's side, suggesting potential head trauma and chest injury. Primary Survey (ABCDE Assessment) 1. Airway: - Airway patent, no obstruction noted. - No intervention performed. 2. Breathing: - Respiratory rate: 22 breaths per minute. - Oxygen saturation: 92% on room air. - Breathing sounds: Clear bilateral lung sounds, slight wheeze noted on expiration. - Intervention performed: Administered 4L/min oxygen via nasal cannula. 3. Circulation: - Heart rate: 110 bpm. - Blood pressure: 90/60 mmHg. - Capillary refill time: 3 seconds. - Perfusion status: Poor perfusion, cool extremities. - Intervention performed: Initiated rapid IV fluid resuscitation with 1 litre 0.9% NaCl wide open. 4. Disability (Neurological): - Glasgow Coma Scale (GCS): E4V4M6 (Total 14), alert and oriented to person, place, and time. - Pupillary response: Pupils equal and reactive to light bilaterally. - Level of consciousness: Alert. 5. Exposure/Environment: - Temperature: 36.8°C. - Skin condition: Multiple abrasions noted on the left arm and leg. Small laceration on the forehead, not actively bleeding. Skin cool and clammy. - Bleeding: Minor superficial bleeding from forehead laceration, controlled with direct pressure. Secondary Survey (Head to Toe Assessment): Further assessment revealed a palpable deformity and crepitus over the left distal tibia, suggestive of a fracture. No other gross deformities or significant injuries noted during head-to-toe examination. Abdomen soft, non-tender. Pelvis stable. Diagnostic Testing: X-ray of the left tibia/fibula ordered, showing a displaced spiral fracture of the distal tibia. CT scan of the head and chest also ordered due to mechanism of injury and initial SpO2 reading. Plan and Recommendations: Administer analgesia for pain. Orthopaedic consultation for left tibia fracture. Continue IV fluid resuscitation to improve blood pressure. Monitor GCS, vital signs, and SpO2 closely. Prepare for potential intubation if respiratory status deteriorates. Surgical referral for tibia fracture repair once stable. Report prepared by: Dr. Sarah Williams Date: 01/11/2024