TTL Note

The clinician's specialty is Emergency Medicine Registrar. **Pre-arrival Information:** Trauma alert activated for a 35-year-old male involved in a high-speed motor vehicle collision. Mechanism of injury involved frontal impact with significant intrusion. Estimated time of injury was approximately 45 minutes prior to arrival. Advance notification received from paramedics indicated potential polytrauma with haemodynamic instability. **Paramedic Handover Summary:** * Patient found entrapped in vehicle, extrication took 20 minutes. * Initial GCS 13 (E3V4M6), pupils equal and reactive. * BP 90/60 mmHg, HR 120 bpm, RR 22 bpm, SpO2 92% on room air. * Interventions: Application of cervical collar, bilateral IV access obtained (18G in each antecubital fossa), 1 litre normal saline bolus administered, patient intubated roadside for airway protection due to declining GCS, bilateral chest decompression performed after suspected tension pneumothorax. * Condition during transfer: Ongoing haemodynamic instability requiring further fluid bolus (500ml normal saline), pupils remained equal and reactive, no further drop in GCS post-intubation. **Primary Survey Findings:** * **Airway:** Intubated, secure, bilateral equal breath sounds confirmed. * **Breathing:** Bilateral chest drains in situ, minimal air leak on right, moderate serosanguinous fluid from left. Chest wall tenderness noted, paradoxical movement of left chest wall. * **Circulation:** Tachycardic (HR 118 bpm), hypotensive (BP 88/55 mmHg). Peripheral pulses weak but present. Capillary refill time 4 seconds. Pelvis stable to compression. No obvious external haemorrhage. * **Disability:** GCS RTH (recorded as Tube) due to intubation. Pupils 3mm, equal and reactive to light. No focal neurological deficits noted. * **Exposure:** Patient fully exposed. Multiple abrasions and contusions noted across chest and abdomen. Obvious open fracture of left tibia/fibula, actively bleeding. **Secondary Survey Findings:** * **Head:** Small laceration to forehead, no palpable skull deformity. Ocular exam unremarkable. Ear/nose/throat exam clear. * **Neck:** C-collar in place. No crepitus. Jugular venous distension not noted. * **Chest:** Asymmetrical chest movement, severe tenderness over left ribs 3-7. Subcutaneous emphysema noted over left anterior chest. Breath sounds diminished on left. * **Abdomen:** Distended, tender to palpation diffusely, especially in upper quadrants. Bowel sounds sluggish. Seatbelt sign evident across lower abdomen. * **Pelvis:** Stable to compression. No signs of open book injury. * **Extremities:** Right upper limb: no obvious injury. Left upper limb: small laceration to forearm. Right lower limb: no obvious injury. Left lower limb: open fracture of tibia and fibula with significant soft tissue damage, actively bleeding. * **Neurological:** Gross motor and sensory examination limited due to intubation and sedation, but withdrawal to painful stimuli symmetrical. Reflexes intact. **Interventions Performed:** * Rapid sequence intubation (RSI) with Etomidate and Rocuronium. * Two large bore IV cannulas placed. * 2 litres of warmed normal saline administered. * 2 units of O negative blood transfused. * Bilateral chest drains inserted. * Pelvic binder applied as a precaution. * Wound dressing and splint applied to left open tibial fracture. * Pain control initiated with Fentanyl IV. * Tranexamic acid 1g IV administered. **Investigations:** **Blood Tests:** * FBC: Hb 8.5 g/dL, WCC 18.2 x 10^9/L, Platelets 220 x 10^9/L. * Biochemistry: Na 140 mmol/L, K 4.2 mmol/L, Creatinine 90 µmol/L. * Coagulation: PT 18s, APTT 45s, INR 1.5. * Group and Crossmatch: O Rh negative. **VBGs:** * pH 7.18 * Lactate 6.8 mmol/L * Base Excess -10 mmol/L * HCO3 16 mmol/L X-rays: * Chest X-ray: Left sided haemopneumothorax, multiple left rib fractures (3-7), widened mediastinum. Right lung field clear. * Pelvis X-ray: Stable pelvis, no obvious fracture. * Cervical Spine X-ray: C1-C7 alignment maintained, no acute fracture or subluxation. CT Scans: * CT Head: No intracranial haemorrhage or mass effect. Mild cerebral oedema. * CT Chest: Bilateral haemopneumothoraces (larger on left), multiple left rib fractures (3-7) with flail segment. Aortic dissection suspected at isthmus. * CT Abdomen/Pelvis: Splenic laceration grade III, mesenteric haematoma, free fluid in abdomen and pelvis consistent with haemorrhage. Left kidney contusion. **Summary of Traumatic Diagnosis:** 35-year-old male with polytrauma following high-speed MVC. Diagnoses include traumatic brain injury (mild cerebral oedema), flail chest with bilateral haemopneumothoraces, suspected traumatic aortic injury, splenic laceration grade III, mesenteric haematoma, left kidney contusion, and open left tibia/fibula fracture. Patient is in haemorrhagic shock. Clinical impression is severe polytrauma requiring immediate surgical intervention. **Discussion with Specialties and Disposition:** Immediate discussion held with the General Surgical team, Orthopaedic team, and Cardiothoracic Surgical team. General Surgery advised for emergent laparotomy due to active abdominal bleeding. Orthopaedics advised for urgent theatre for open tibial fracture debridement and external fixation. Cardiothoracics advised for further evaluation of suspected aortic injury in theatre. Patient is being transferred directly to theatre for damage control surgery. Dr. Sarah Chen Emergency Medicine Registrar MBBS, FRCP(EM)