ED Primary Survey

Emergency Trauma Assessment 34 M BIBA Fall from height onto concrete. **Pre-Arrival:** Pre arrival Notification: Pre-hospital report indicates a 34-year-old male found at the base of a 3-storey building. GCS 10 (E3V3M4) en route. BP 90/60, HR 120, RR 24. Spinal immobilisation and two large bore IVs initiated with 1L normal saline infused. Mechanism of Injury: Blunt trauma. Patient fell approximately 9 meters onto concrete. No vehicle involvement. Minimal blood at scene reported by EMS. No other fatalities. Trauma call: Yes, activated due to significant mechanism of injury and altered mental status. **Arrival:** Time of Patient Arrival: 1 November 2024, 09:30 Trauma Team Activation Time: 1 November 2024, 09:25 Team Members Present: Dr. Eleanor Vance (EM Registrar), Dr. Thomas Kelly (Consultant EM), Nurse Sarah Jenkins (Trauma Coordinator), Paramedic John Smith, Respiratory Therapist Mark Lee. **EMS Hand-off:** Time of Handoff Completion: 1 November 2024, 09:38 Key Findings from EMS Report: Initial vital signs: BP 90/60, HR 120, RR 24, SpO2 92% on room air. GCS 10. Received 1L Normal Saline en route. Spinal immobilisation applied. Patient conscious but confused, complaining of severe back pain and left leg pain. Paramedic Handover - Mechanism of Injury: Paramedics reported the patient was found by a passerby at the base of a construction site. Witness observed patient falling from a significant height, estimated at 3 floors. Patient was initially unconscious for an unknown duration but roused to verbal stimuli. **Immediate Life Threats Noted:** Hemodynamic instability (hypotension, tachycardia), decreased level of consciousness, potential for significant internal haemorrhage, suspected spinal injury. **Primary Survey (ABCDE Assessment):** **Vital Signs:** RR: 28 SpO2: 96% HR: 118 BP: 85/55 MAP: 65 T: 36.8 C GCS: 9 E: 2 V: 3 M: 4 Central Capillary Refill Time: >3 seconds, prolonged. **Airway & C-spine:** Patent: Airway patent, no obstruction due to blood, vomit, or foreign bodies. Verbal Response: Responds to pain, moaning, unable to follow commands. Airway Interventions: None required immediately, airway adjuncts (OPA) at bedside for immediate use if needed. Jaw thrust maintained by nurse. Cervical collar (Philadelphia type) in place, spine precautions maintained. **Breathing:** Chest Wall Examination: Equal chest rise bilaterally. No paradoxical movement. Tenderness on palpation over posterior chest wall, particularly left lower ribs. No crepitus noted. Trachea Position & JVD: Trachea midline. No jugular venous distension observed. Breath Sounds: Bilateral breath sounds present, diminished at left lung base. Oxygenation/Ventilation: SpO2 96% on 10L non-rebreather mask. End-tidal CO2 not yet initiated. **Circulation:** External Bleeding: Small laceration to forehead, controlled with direct pressure. No other obvious external bleeding sites. Internal Bleeding Suspicion: eFAST performed, positive for free fluid in Morison's pouch and splenorenal recess, concerning for intra-abdominal haemorrhage. Blood Pressure & Pulses: BP 85/55 mmHg. Radial pulses weak but palpable bilaterally. Dorsalis pedis pulses weak but present bilaterally. Pelvic Stability & Intervention: Pelvis unstable on gentle compression. Pelvic binder placed immediately due to suspected open book fracture, confirmed by X-ray. Blood products transfused: 2 units packed red blood cells, 1 unit fresh frozen plasma initiated. Details of vascular access established: Right antecubital 16G IV, Left femoral 14G IV. No arterial line established yet. **Disability (Neurologic Status & Cervical Spine Status):** Pupil Examination: Pupils 4mm, sluggishly reactive to light bilaterally. Equal. Extremity Movement: Withdraws from painful stimuli in all four extremities. Decreased movement in left lower extremity, unable to assess fully due to pain. **Exposure:** Complete Undressing: Patient fully exposed for assessment. Hypothermia Prevention: Warm blankets applied, IV fluids warmed. Log Roll for Back Assessment: Performed with spinal precautions. Large contusion noted over lumbar spine, no obvious step-off. No saddle anaesthesia observed. **Assessment & Plan:** Summary of Findings: 34-year-old male with severe blunt trauma following a 9-meter fall, presenting with hypovolemic shock (BP 85/55, HR 118) and altered mental status (GCS 9) with positive eFAST and unstable pelvis. * Hypovolemic shock secondary to suspected intra-abdominal and pelvic haemorrhage. * Polytrauma including suspected spinal injury (lumbar contusion), left lower limb injury, and potential thoracic injury (diminished left lung sounds). * Head injury with GCS 9 and sluggish pupils. Interventions Performed: * Spinal immobilisation and cervical collar application. * Two large-bore IVs established; 1L Normal Saline and 2 units PRBCs, 1 unit FFP infused. * Oxygen via non-rebreather mask at 10L/min. * Pelvic binder placed. * eFAST performed, positive. Pending Procedures & Investigations: * CT head, C-spine, chest, abdomen, and pelvis. * Orthopaedic consultation for pelvic injury and left lower limb. * General surgery consultation for intra-abdominal haemorrhage. * Central venous access placement. * Arterial line placement for continuous BP monitoring. * Further blood product transfusion based on ongoing bleeding and lab results. Disposition: * Operating room for exploratory laparotomy and pelvic stabilisation. Consultations: * General Surgery * Orthopaedics * Neurosurgery (on standby) Clinician Specialty: Emergency Medicine Registrar