DHS ED Trauma

Trauma M = The patient was involved in a high-speed motor vehicle collision, with the vehicle sustaining significant front-end damage. The incident occurred approximately 30 minutes prior to arrival. I = Right femur fracture, closed. Possible head injury. Multiple abrasions to the face and upper extremities. S = HR 110 bpm, BP 100/60 mmHg, RR 24 breaths/min, SpO2 96% on room air, GCS 13, Temp 37.1°C. T = IV access established, 2L crystalloid bolus administered. Oxygen via non-rebreather mask. Cervical spine immobilisation with collar. Primary Survey: Airway patent, breathing adequate with bilateral equal air entry, circulation compromised with tachycardia and hypotension, disability assessed with GCS 13, exposure revealed multiple abrasions and a right femur deformity. No immediate life threats identified. C-Spine: C-spine immobilised and cleared clinically using NEXUS criteria. Secondary Survey: Head: Multiple abrasions to the forehead and scalp. No obvious skull deformity. Face: Facial abrasions and swelling. No obvious fractures. Pupils equal and reactive to light. Neck: Cervical collar in place. No tenderness to palpation. Chest: Clear to auscultation bilaterally. No chest wall deformity. Mild bruising noted. Abdomen: Soft, non-tender, no guarding or distension. Pelvis: Stable to palpation. No deformity. Upper Limbs: Abrasions to both upper extremities. No obvious fractures. Lower Limbs: Deformity and tenderness to the right femur. Left lower limb intact. Back: No tenderness or deformity noted on log roll. Neuro: GCS 13. Pupils equal and reactive. Moving all limbs, sensation intact. Assessment: The patient sustained multiple injuries from a motor vehicle collision, including a right femur fracture and possible head injury. The patient is haemodynamically stable but requires further investigation and management. The mechanism of injury suggests a high risk of serious injury. Plan: 1) X-rays of the right femur, chest, pelvis, and cervical spine. CT head and C-spine. Blood tests including full blood count, coagulation studies, and biochemistry. 2) Analgesia with IV morphine. Right femur splinting. Continued monitoring of vital signs and neurological status. Further fluid resuscitation as needed. 3) Admission to the trauma service. Orthopaedic consultation. Further management and disposition to be determined following imaging and specialist review. Safety netting provided to the patient and family.