Trauma note

Specialty: General Practitioner Trauma note Profile: Patient John Doe, 45 years old, sustained blunt trauma from a head-on motor vehicle crash. He was the restrained driver involved in a high-speed collision with another vehicle. Level of trauma activation: Level 1 Trauma Activation. Primary Survey: EMS vitals: Heart rate 110 bpm, blood pressure 90/60 mmHg, respiratory rate 22 bpm, oxygen saturation 92% on room air, glucose 115 mg/dL. Shock index: 1.22. First set of in-hospital vitals: Heart rate 105 bpm, blood pressure 95/65 mmHg, respiratory rate 20 bpm, oxygen saturation 94% on 4L nasal cannula, glucose 120 mg/dL. Shock index: 1.11. Airway: Patient is maintaining his own airway with occasional gurgling sounds, suggestive of possible blood in the pharynx. No foreign objects noted. Airway interventions included manual jaw thrust on arrival to maintain patency. Breathing: Chest examination reveals diminished breath sounds on the left base with paradoxical chest wall movement. Work of breathing is laboured with accessory muscle use. Oxygen delivered via nasal cannula at 4 litres per minute, subsequently increased to 10 litres per minute via non-rebreather mask due to persistent desaturation. No needle decompression or chest tube insertion performed prior to this assessment. Circulation: Visible external bleeding from a laceration on the left forehead, controlled with direct pressure. Abdominal examination reveals tenderness in the left upper quadrant. Pelvis is stable to palpation. Suspected left femoral fracture based on deformity and crepitus. Capillary refill is delayed at 3 seconds, and extremities are cool to touch. Initial management included direct pressure to the forehead laceration and application of a pelvic binder due to mechanism of injury. Vascular access obtained: Two large-bore intravenous lines (16G) in the right and left antecubital fossae. Initial fluid resuscitation ordered, specifying 1 litre of normal saline as a bolus. Disability: Total GCS score 13 (Eyes: 3, Verbal: 4, Motor: 6). Pupils are 4mm bilaterally, reactive to light and equal. Motor and sensation intact in all four limbs, though pain limits full assessment of the left lower extremity. No focal neurological deficits identified. First glucose recorded: 120 mg/dL. Management of any suspected raised intracranial pressure or low glucose: No signs of raised intracranial pressure, glucose is within normal limits. Cervical spine was not clinically cleared and a hard cervical collar was applied by EMS and remains in place. Environmental and Exposure: Patient temperature: 36.5°C. A log roll was performed, revealing a small abrasion on the patient's upper back, otherwise unremarkable. No spinal tenderness. Digital rectal exam was performed and findings revealed normal rectal tone and no gross blood. No high-riding prostate. Adjuncts: POCUS: FAST exam revealed free fluid in Morison's pouch and splenorenal space, suggestive of intra-abdominal hemorrhage. Labs: Initial laboratory results showed Hb 10.5 g/dL, Hct 31%, Platelets 250 x 10^9/L, INR 1.1, PTT 30 seconds, Lactate 3.2 mmol/L. Electrolytes were within normal limits. Initial Imaging: Chest x-ray revealed left-sided rib fractures and a small left haemothorax. Pelvic x-ray was negative for fracture. AMPLE History: Allergies: Known allergies: Penicillin (hives). Medications: Patient's home medications: Lisinopril 10mg daily for hypertension. Date or status of last tetanus immunisation: Unknown, but patient states he believes it was within the last 5 years. Past Medical History: Relevant past medical history: Hypertension, controlled on medication. Last Meal: Time and content of last meal: Approximately 3 hours prior to the accident, a sandwich and a fizzy drink. Events Prior: Description of events leading up to the trauma, including who provided the history such as the patient, EMS, police, or a family member: History obtained from EMS and partially from the conscious patient. EMS reported a high-speed head-on collision. Patient stated he was driving home from work when the other vehicle swerved into his lane. Secondary Survey: Repeat set of vitals obtained after the primary survey: Heart rate 115 bpm, blood pressure 90/55 mmHg, respiratory rate 24 bpm, oxygen saturation 93% on non-rebreather mask. Head to toe physical examination with all findings documented and all interventions performed in response to those findings: Head: 4 cm laceration to the left forehead, cleaned and dressed. Neck: No step-offs or tenderness beyond C-collar. Chest: Decreased breath sounds left base, paradoxical movement left chest wall, multiple crepitations on palpation. Abdomen: Distended, rigid, exquisitely tender in the left upper quadrant. Pelvis: Pelvic binder in situ. Extremities: Left thigh deformed, painful to palpation, open fracture suspected due to small laceration with visible bone fragment. Right upper extremity normal. Left upper extremity normal. Right lower extremity normal. Back: Abrasion noted, no further injuries. Interventions included further pain management with IV fentanyl, covering the open fracture site with a sterile dressing, and continued fluid resuscitation. Any additional imaging performed after the initial chest and pelvic x-rays: Computed Tomography (CT) scan of the head, neck, chest, abdomen, and pelvis was performed, confirming left pneumo/haemothorax, splenic laceration with active extravasation, and comminuted left femoral shaft fracture. Assessment: Patient, 45 years old, sustained severe blunt polytrauma. He is currently haemodynamically unstable due to active haemorrhage. List of patient injuries in order of severity, beginning with the most severe: 1. Splenic laceration with active extravasation, causing intra-abdominal haemorrhage and haemodynamic instability. 2. Left pneumo/haemothorax with multiple rib fractures. 3. Open comminuted left femoral shaft fracture. 4. Head laceration. 5. Generalised contusions and abrasions. Treatment in Facility: All treatments performed in the emergency department including all medications administered with dose and route, all procedures performed in detail, and all fluids given with volumes for each: Intravenous access established with two 16G cannulas. Pain managed with Fentanyl 50mcg IV every 15 minutes as needed (total 150mcg given). Tranexamic Acid 1g IV administered over 10 minutes. 2 litres of normal saline given as IV boluses. 2 units of O-negative packed red blood cells transfused. Left chest tube inserted for haemothorax (28 Fr). Sterile dressing applied to the open femoral fracture. Pelvic binder placed. Patient stabilised for transfer. Summary of Red Call: Conference call with the trauma surgeon, orthopaedic surgeon, and interventional radiologist. Consensus reached to proceed with damage control laparotomy, followed by orthopaedic intervention for the femoral fracture once stable. Interventional radiology on standby for potential embolisation. Plan: Transfer plan: Patient will be transferred to a Level 1 Trauma Centre, St. George's Hospital, via RISE Air ambulance. The receiving service will be the Trauma Surgery team. Expected arrival within 60 minutes. Final vitals prior to leaving the department: Heart rate 120 bpm, blood pressure 85/50 mmHg, respiratory rate 26 bpm, oxygen saturation 92% on non-rebreather mask. Shock index: 1.41.