**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.
