Emergency Trauma Assessment (Primary Survey Notes)

Patient Age: 34, Patient Gender: M, BIBA, Patient was involved in a high-speed motor vehicle collision. Pre-Arrival: - Personal Protective Equipment (PPE): Gloves, masks, and face shields worn by team members. - EMS Notification: Patient was ejected from the vehicle, sustained blunt trauma, field vitals were BP 90/60, HR 120, RR 28, SpO2 92%, pre-arrival interventions included IV fluids and oxygen. - Mechanism of Injury: High-speed motor vehicle collision, patient ejected, significant vehicle damage, presence of blood at the scene. - Trauma Activation Criteria: Level I activation triggered due to high-speed collision and ejection. Arrival: - Time of Patient Arrival: 14:32 - Trauma Team Activation Time: 14:33 - Team Members Present: Dr. Thomas Kelly (EM physician), Dr. Sarah Lee (trauma surgeon), Nurse John Smith, RT Emily Davis - EMS Hand-off: - Time of Handoff Completion: 14:35 - Key Findings from EMS Report: BP 90/60, HR 120, RR 28, SpO2 92%, IV fluids and oxygen administered, blunt trauma from ejection. - Immediate Life Threats Noted: Agonal respirations, significant external bleeding from the left leg. Primary Survey (ABCDE Assessment): Vital Signs: RR: 28, SpO2: 92%, HR: 120, BP: 90/60 (MAP: 70), T: 36.5C, GCS: 10 (E: 3, V: 3, M: 4) Central Capillary Refill Time: Delayed Airway: - Patent: Blood present, suctioning performed - Verbal Response: Incoherent sounds, stridor noted - Airway Interventions: Suctioning and intubation performed Breathing: - Chest Wall Examination: Bruising on the left side, crepitus noted - Trachea Position & JVD: Trachea midline, no JVD - Breath Sounds: Decreased breath sounds on the left - Oxygenation/Ventilation: O2 saturation 92%, EtCO2 45 mmHg Circulation: - External Bleeding: Significant bleeding from left leg, tourniquet applied - Internal Bleeding Suspicion: E-FAST positive 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 lower extremities - Cervical Spine (Status and precautions taken): In Cx Spine precautions - Collar: Yes, rigid collar placed at 14:34 Exposure: - Complete Undressing: Patient fully exposed for assessment - Hypothermia Prevention: Warm blankets applied - Log Roll for Back Assessment: No saddle anesthesia, bruising noted on the back