A patient was brought to the ER after a road traffic accident, suffering severe head injuries and multiple fractures. Despite being intubated and sedated, the patient's condition remained critical with unequal pupils and a Glasgow Coma Score of 2. The family declined further management, leading to a discharge against medical advice after stabilization and initial treatment.

1. Case Presentation

2. Brief History
Patient brought to ER on 04/06/2024 @ 1:54 pm with alleged h/o RTA
Three wheeler (Auto) hit against the wall near ChittiKadu and sustained
injury to the multiple regions

3. Secondary Survey
S -
A –Not Known
M -Not Known
P - Not Known
L - Not Known
E - Not Known

4. General Examination
Intubated ,Sedated and ventilated
No pallor, icterus, clubbing,cyanosis, Pedal Edema, Lymphadenopatty
CVS:S1S2(+),No murmur
RS:BAE(+) decreased over the left
P/A: Soft, BS(+)
CNS: Pupils unequal reacting to light
GCS:2T/15

5. Systemic Examination
HEAD ,Neck and MAXILLOFACIAL
 Abrasion over the left side of the cheek
 Laceration in the supraorbital region
size: 4x2 cm
 Laceration in the right upper lip (2x1x1cm)
 Philtrum abrasion (+)
CHEST
 Bilateral chest wall movements (+)
 use of accessory respiratory muscles (+)
 No Tracheal deviation
 No deformity, swelling, subcutaneous emphysema ,
open/blunt injury
 Decrease air entry noted over left side
 No added sounds
 Dullness noted over the left side
INTERVENTION
 Airway secured ,continued ventilation and sedation
 GCS:2T/15 pupils reacting to the light 1.5 mm right
eye and 2 mm left eye
 Maintain adequate in-line immobilization and
protection of the cervical spine
 Wound care management done
 For laceration suturing done
 Xray – left side white out lung
 PLAN -CT imaging

6. ABDOMEN AND PELVIS
No signs of blunt and penetrating injury and internal
bleeding.
bowel sounds (+)
On compressing ,Pelvis Tenderness not elicited
PERINEUM/RECTUM/VAGINA
No Contusions and hematomas,Lacerations ,Urethral
bleeding
No Rectal blood B.
Anal sphincter tone- normal
No blood in vaginal vault
Efast - negative
No extraperitoneal bleed
X ray pelvis taken bedside no obvious injury found
NIL

7. Adjunts to the Secondary survey
• Spinal X-rays
• CT Brain, PNS

8. Diagnosis
RTA/SEVERE HEAD INJURY/DIFFUSE AXON INJURY/LATERAL
WALL OF ORBITAL FRACTURE/LATERAL WALL OFMAXILLARY
BONE FRACTURE

9. Treatment in ER
Intubated, sedated , ventilated
Prop up position 15 degree
INJ TETANUS TOXOID
INJ LEVIPIL 1 G IV STAT
INJ PANTOPRAZOLE 40M G IV STAT
INJ EMESET 4MG IV STAT
INJ XONE 1 G IV STAT
INJ METROGYL 500 MG IV STAT
INJ TRAPIC 1 G IV STAT

10. Speciality opinion
• NEUROSURGERY
• ORTHOPEDICS
• GENERAL SUGERY

11. Neurosurgery advised ICU Admission
Plan Emergency thoracotomy
Kindly collect the pending lab reports
Explained to the attenders in an understable language
Orthopedician requested for CT Pelvis fracture
General surgery Nil intervention
Patient attenders not willing for futher management
Discharge against medical advice