Obtained history and collateral by paramedics on arrival.
HPI:
_ y/o _ w/ PMH of _, presents as trauma.
(Level of activation): patient presented as trauma _
Allergies: NKDA
Medications: none
PMH/PSH: none
Tetanus: unknown
Events prior to presenting to ED:
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
Imaging:
_ CXR (eval for traumatic chest injury)
(Not indicated when: 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 CDIBT 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: Trauma,
DISPOSITION:
COUNSELLING: Patient/family educated on diagnostics, assessment, treatment plan. Patient/family amendable and in agreement with plan. All questions and concerns answered and addressed.
SUPERVISION: Discussed and obtained approval/confirmation of evaluation (history/exam/diagnostics) and plan (assessment/interventions/disposition) with ED attending physician