HPI:
_ y/o _ w/ PMH of _, presents after MVC
Events prior to presenting to ED:
_ time of accident
_ type of collision
_ Estimated speed of vehicles
_ (location of the patient in the vehicle during the collision)
_ restrained with seatbelt
_ significant passenger compartment intrusion
_ self extricated
_ significant injury to other passengers or people involved in accident
_ vehicle drivable after the accident
_ ambulated after accident
_ loss of consciousness
_ head strike
_ on blood thinners/ASA
_ intoxication or recent alcohol or illicit drug use
_ solo unaccompanied driver
Current complaints of region of pain (location of body): _
REVIEW OF SYSTEMS:
unable to be obtained secondary to pt’s condition
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Primary Survey:
– Airway: Patent, oropharynx clear, trachea midline
– Breathing: Symmetric breath sounds, equal chest rise
– Circulation: Palpable radial peripheral pulse (BP as above), IV access obatined, pt on monitor
– Disability: GCS E4 V5 M6
– Exposure: Exposed patient for full examination (subsequent to examination, pt covered in warm blanket)
Secondary Survey:
– Head: Atraumatic, no scalp lacerations, no retroauricular ecchymosis
– Eyes: PERRL, EOMI, no orbital trauma/crepitus.
– Face: Atraumatic (No midface signs of trauma, no tenderness/instability, no mandibular tenderness or instability, no septal hematoma)
– Neck: No midline TTP, no step offs, cervical collar in place.
– Chest: Atraumatic (no seat belt sign/ecchymosis/abrasions/no crepitus)
– CV: RRR
– Resp: Lungs BLTA, symmetric,
– Abdomen: Atraumatic (non-tender, non-distended, no ecchymosis/lacerations/penetrations)
– Pelvis: Stable, no pelvic tenderness
– Extremities: No deformities, Pulses+motor+sensation intact in all 4 extremities
– Back: Atraumatic no stepoffs, no midline TTP
– GU: Perineum intact, no blood at ureathral meatus, able to squeeze buttock
.
ED COURSE:
Per ATLS protocol, primary survey performed emergently upon pt’s arrival, any abnormalities addressed. RNs exposed pt, placed on monitor and secured IV access. Secondary survey performed.
DIAGNOSTICALLY:
Labs:
Type and screen and standard trauma labs sent
_ pregnancy test
Imaging considered:
_ CXR (eval for traumatic chest injury)
(Not indicated when all of the following characteristics are met: age<60, no rapid dec (fall<20ft, MVC<40mph, no CP, no TTP on CW, not intox/AMS, no distracting injury)
Reviewed indications, applied NEXUS chest criteria to this patient to inform appropriate use of diagnostics).
_ PXR (eval for pelvic traumatic injury
(Not indicated when: Non-dangerous mechanism, no pelvic pain, ambulatory).
Reviewed indications, applied to this patient to inform appropriate use of diagnostics).
_ CT head (eval for acute intra-cranial traumatic process and bony fxr)
(Not indicated when: no dangerous mechanism (PMVT, ejection, fall>3ft), GCS>=13, no coagulopathy, no open skull fxr, 16<age<65, vomiting <=2x, no open/depression skull fxr, no s of basal skull fxr, GCS 15 @ 2 hrs, no retrograde amensia >30 min).
Reviewed indications, applied Canadian head criteria to this patient to inform appropriate use of diagnostics).
_ CT C-spine (eval for acute traumatic bony injury)
(Indications: GCS<15, intoxication/distracting injury, 16>age<65, parathesias, previous spine dz/surgeries, no dangerous mechanism (MVC>60mph, rollover, ejection, recreational motor vehicle, bike-MVC, then CT. If none of above, then if any low risk factors (no neck pain, simple rear end MVC, sitting position, ambulatory, delayed neck pain), then safe for ROM. If ROM w/o pain, then CT not indicated.
Reviewed indications, applied Canadian c-spine criteria to this patient to inform appropriate use of diagnostics).
_ CT chest (eval for traumatic intra-thoracic injury)
(Not indicated when: no severe mechanism c/w intrathoracic injury, no signs of chest wall trauma, not extremes of age, no cardio-pulmonary distress)
Reviewed indications, applied to this patient to inform appropriate use of diagnostics).
_CT a/p
(Indications: severe mechanism c/w intra-and injury, TTP abd, signs of intra-abd injury, +FAST, un-evaluable pt with suspected abd injury)
Reviewed indications, applied to this patient to inform appropriate use of diagnostics).
_ XRs to eval for fracture/dislocation (Indications: sx(pain)/signs(of trauma) in extremities. Not indicated: no extremity s/s trauma in extremities. Reviewed indications, applied to this patient to inform appropriate diagnostics)
THERAPEUTICALLY:
NPO, Observation on monitor.
MDM:
DIAGNOSIS: MVC
DISPOSITION:
_ Home.
RE-EVALUATION: Given appreciation that dramatic injuries can have falsely reassuring examinations on initial presentation, the patient was observed in the emergency department and serial examinations were performed. Upon repeat examination prior to time of discharge, the abdomen was soft, nontender thereby yielding a benign abdominal exam. The patient was ambulatory without any complaints of significant pain on extremities or joints . The patient’s mental status was normal with the patient exhibiting a clear sensorium and clinically sober. given potential for a dramatic stress and/or medications are ministered in the emergency department, the patient was advised not to drive and was amenable to obtaining transportation home by friends/family.
_ Admitted
COUNSELLING: Patient/family educated on diagnostics, assessment, treatment plan. Patient/family amendable and in agreement with plan. All questions and concerns answered and addressed.