Emergency Trauma Assessment

**Emergency Trauma Assessment** 35 F BIBA Severe head trauma following a high-speed motor vehicle collision. **Pre-Arrival:** - Personal Protective Equipment (PPE): Gloves, masks, and gowns worn by all team members. - EMS Notification: Patient involved in a high-speed collision, ejected from vehicle, field vitals: BP 90/60, HR 120, RR 28, SpO2 88%. Pre-arrival interventions included cervical spine immobilization and oxygen administration. - Mechanism of Injury: Blunt trauma from high-speed impact, significant vehicle damage, presence of blood at the scene. - Trauma Activation Criteria: Level I activation due to severe head injury and hemodynamic instability. **Arrival:** - Time of Patient Arrival: 14:30 - Trauma Team Activation Time: 14:32 - Team Members Present: Dr. Thomas Kelly (EM physician), Dr. Sarah Lee (trauma surgeon), Nurse Jane Doe, RT John Smith. - **EMS Hand-off:** - Time of Handoff Completion: 14:35 - Key Findings from EMS Report: GCS 8, agonal respirations, significant scalp laceration. - **Immediate Life Threats Noted:** Agonal respirations, exsanguination from scalp laceration. **Primary Survey (ABCDE Assessment):** **Vital Signs:** RR: 28, SpO2: 88%, HR: 120, BP: 90/60 (MAP: 70), T: 36.5C, GCS: 8 (E: 2, V: 2, M: 4) Central Capillary Refill Time: Delayed **Airway:** - Patent: Obstructed by blood and vomit. - Verbal Response: Incomprehensible sounds. - Airway Interventions: Suctioning performed, intubation required. **Breathing:** - Chest Wall Examination: Bruising on the right side, decreased movement. - Trachea Position & JVD: Midline, no JVD. - Breath Sounds: Decreased on the right side. - Oxygenation/Ventilation: O2 saturation 88%, EtCO2 50 mmHg. **Circulation:** - External Bleeding: Scalp laceration controlled with pressure dressing. - Internal Bleeding Suspicion: Positive E-FAST for free fluid in the abdomen. - Blood Pressure & Pulses: BP 90/60, weak radial pulses bilaterally. - Pelvic Stability & Intervention: Pelvic binder placed due to instability. **Disability (Neurologic Status & Cervical Spine Status):** - Pupil Examination: PEARL bilat. - Extremity Movement: Limited movement in all extremities. **Cervical Spine (Status and precautions taken):** In Cx Spine precautions. - Collar: Yes, rigid collar placed at 14:32. - **Exposure:** - Complete Undressing: Patient fully exposed for assessment. - Hypothermia Prevention: Warm blankets applied. - Log Roll for Back Assessment: No saddle anesthesia, large bruising on lower back. **Secondary Survey:** - **AMPLE History:** - Allergies: NKDA - Medications: Unknown - Past Medical History: Nil Significant - Last Meal: Unknown - Events Leading to Injury: High-speed collision, ejected from vehicle. - **Physical Exam:** - Head & Face: Large scalp laceration, facial asymmetry. - Cervical Spine: Tenderness, imaging required. - Thorax: Right rib fractures, HSDNM. - Abdomen/Pelvis: Tenderness, positive rebound, unstable pelvis with binder in situ. - Extremities: Deformities in right leg, weak pulses, gross sensation intact. - Back: Tenderness over lumbar spine, large bruises. - Digital Rectal Exam: Not indicated. **Assessment & Plan:** - Summary of Findings: Severe head trauma, GCS 8, hemodynamic instability. - Interventions Performed: Intubation, pelvic binder, fluid resuscitation. - Pending Procedures & Investigations: CT head, chest tube placement. - Disposition: ICU admission. - Consultations: Trauma surgery, neurosurgery.