Downloaded 11 times
Uploaded byfarranajwa
Case scenario 22042021 (batch c2)
A 35-year-old man was found unconscious and hypotensive after being brought to the emergency department by ambulance. On assessment he had a decreased level of consciousness, tachycardia, hypotension, respiratory distress, and decreased oxygen saturation. He required intubation due to the absence of a gag reflex. Further assessment found left hemothorax requiring chest tube insertion and blood transfusion for hypotension. The patient's condition deteriorated and Beck's triad was identified, likely due to pericardial tamponade requiring emergency thoracotomy, pericardiocentesis, or pericardiectomy. A second patient, a 30-year-old man, presented after being shot and had an open pneum
More Related Content
![Abdominal compartment syndrome[1]](https://cdn.slidesharecdn.com/ss_thumbnails/abdominalcompartmentsyndrome1-121012075429-phpapp02-thumbnail.jpg?width=640&height=640&fit=bounds)
Similar to Case scenario 22042021 (batch c2)
Case scenario 22042021 (batch c2)
- 1. Batch c2 Case scenario2 22042021 A 35-year-old man was found unconscious on the roadside. He was brought in by ambulance. Vitals: HR 125 per min, tachycardia BP 85/55, hypotensive RR 25, respiratory distress O2 90% under HFM, not maintain optimum Spo2 at room air 1. Perform airway assessment Identification Intervention No gag reflex ● Assess patient’s level of consciousness ● Do cervical spine immobilization ● Open airway with jaw thrust and assess airway patency ● Clear the airway from blood or any secretion by doing suction, if there is foreign body then remove it with McGill forceps or fingers ● Insert OPA ● Give humidified high flow O2 - 10 to 15L/min, non rebreather mask Definite management: May require intubation since there is absence of gag reflex
- 2. Batch c2 2. Performbreathing assessment Identification Intervention Look: tachypnea, use of accessory muscle, asymmetrical in chest movement, stridor Feel : percussion, crepitance Listen: absent or decreased breath sounds, additional sounds. Tachypneic Reduced chest movement on left side Tracheal shifted to right Dullness over left chest Absent breath sound over left chest *suggestive left massive hemothorax - Pulse oximetry to monitor spo2. - Continue high flow oxygen. - Chest tube insertion. - Do a chest x ray. - Thoracotomy - Consider blood transfusion (replace) - Too much blood, clamp the tube After your intervention, vital signs have improved, and you move on to circulation assessment.
- 3. Batch c2 3. Performcirculatory assessment & disability assessment. Circulatory assessment: - Assess level of consciousness by using AVPU Scale - “Open your eyes, squeeze my hand” or squeeze both shoulders firmly. If fail to respond, pt is unresponsive - Assess skin perfusion: pink or pale - Assess pulse: - femoral or carotid artery bilaterally for quality, rate, and regularity - Thready pulse is a sign of hypovolemia - Assess BP, heart sounds - Identify source of hemorrhage: internal or external Intervention - Secure 2 large iv bore cannula. - Draw blood for blood grouping, cross matching and blood investigations. - Administer iv fluids therapy and o negative blood transfusion. - Once cross matching report done prepare for appropriate blood group transfusion - Identify active external bleeding: controlled by direct manual pressure. Disability assessment: ● Examine the pupils noting the size and shape ● Check pupillary response ● Assess for GCS score ○ Eye opening ○ Verbal response ○ Motor response ● Check for lateralizing sign ○ Assess movement of upper extremities ■ Determine upper extremity strength bilaterally, and compare side to side. ○ Assess for movement of the lower extremities. ■ Determine lower extremity strength bilaterally, and compare side to side.
- 4. Batch c2 4. Exposure .You do the log roll and find the following wound: At this stage, Patient condition deteriorates and is hypotensive. You repeat the ABCDE assessment of the primary trauma survey. On circulation assessment: Identification Intervention 1. Neck veins are distended 2. Heart sounds are muffled 3. BP80/35 - Finding consistent with Beck triad - Probably pericardial tamponade - Perform FAST scan (*subxiphoid view/apical 4 chamber view) - Confirm by ECHO 1) Emergency thoracotomy or sternotomy or open pericardiectomy (cardiothoracic surgeon) 2) Administration of intravenous fluid
- 5. Batch c2 3) Ifsurgical intervention is not possible, emergent pericardiocentesis followed by pericardiotomy can be therapeutic. (Temporary) ● Emergent needle pericardiocentesis using long over-the-needle catheter (18-22G) ● Seldinger technique insertion of a flexible catheter at xiphisternum towards left shoulder 45° under US guided; aspiration ~60cc can stabilise BP https://www.google.com/url?sa=i&url=https%3A%2F%2Fwww.aliem.com%2Fdifferen tiating-pericardial-effusion-tamponade- ultrasound%2F&psig=AOvVaw0vXSoyo7dfbdN0BxkfG3Zt&ust=1619151801322000 &source=images&cd=vfe&ved=0CAIQjRxqFwoTCOiH8aWBkfACFQAAAAAdAAAAA BAD https://www.youtube.com/watch?v=jQxX4ONGi58 Pericardial effusion https://www.youtube.com/watch?v=scBvGaG5v0I Pericardiocentesis
- 6. Batch c2 Case scenario3 22042021 A 30-year-old man was shot at his right chest by a man using a revolver after quarrelling over a lady. He was riding a motorbike and tried to hit the assailant but instead he was shot and fell from the motorbike. On arrival at ED where you are stationed as a house officer, he is fully conscious, alert, orientated. He complained of severe pain over the right chest and difficulty in breathing. 1. Perform airway assessment of primary trauma survey. Identification Intervention - Fully conscious - Alert - Oriented ● Assess patient’s level of consciousness ● Do cervical spine immobilization ● Open airway with jaw thrust and assess airway patency ● Clear the airway from blood or any secretion by doing suction, if there is foreign body then remove it with McGill forceps or fingers ● Insert OPA ● Give humidified high flow O2 - 10 to 15L/min, non rebreather mask (based on spo2)
- 7. Batch c2 2. Performbreathing assessment of primary trauma survey. Identification Intervention Look: tachypnea, use of accessory muscle, asymmetrical in chest movement, stridor, contusion, wound Feel : percussion, crepitance Listen: absent or decreased breath sounds, additional sounds. Open chest wound over right chest with hissing sound air going in and out *suggestive open pneumothorax Continue administering high flow oxygen. Cover the wound with 3 side dressing - Tape it securely on only three sides to provide a flutter-valve effect - Place a chest tube remote from the wound as soon as possible - Subsequent definitive surgical closure of the wound is frequently required Chest x ray
- 8. Batch c2 3. Performcirculating assessment of primary trauma survey. Identification Intervention ● Assess level of consciousness by using AVPU Scale ○ “Open your eyes, squeeze my hand” or squeeze both shoulders firmly. If fail to respond, pt is unresponsive ● Assess skin perfusion: pink or pale ● Assess pulse: ○ femoral or carotid artery bilaterally for quality, rate, and regularity ○ Thready pulse is a sign of hypovolemia ● Assess BP, heart sounds ● Identify source of hemorrhage: internal or external Tenderness over pelvic bone Patient lethargic Cold periphery CRT 5 sec : prolonged HR 140: tachycardia BP 60/30: hypotension *4th stage of shock Secure 2 large bore iv cannula. Draw blood for blood grouping, baseline investigations and cross matching. Administer iv fluids and blood transfusion. Pelvic binder/wrap in situ Appropriate referral X ray of cervical vertebra, chest, abdomen, pelvic and long bone) Ct trauma series FAST scan - Hepatorenal pouch - Splenorenal pouch - Pelvic cul-de sac (retrovesical pouch) - Pericardial view
- 9. Batch c2 4. Performdisability assessment of primary trauma survey. Identification Intervention ● Examine the pupils noting the size and shape ● Check pupillary response ● Assess for GCS score ○ Eye opening ○ Verbal response ○ Motor response ● Check for lateralizing sign ○ Assess movement of upper extremities ■ Determine upper extremity strength bilaterally, and compare side to side. ○ Assess for movement of the lower extremities. ■ Determine lower extremity strength bilaterally, and compare side to side. GCS 8/15 GCS 8 and below: prepare for intubation and ventilate CT scan of brain
- 10. Batch c2 5. Exposure IdentificationIntervention Patient is shivering High riding prostate ● Maintain temperature by providing a blanket and warmer to prevent hypothermia that might lead to coagulopathy. ● Warm saline infusion, (blood product must be warm) ● Suggestive of posterior urethral injury - avoid catheterisation, prefer suprapubic cystostomy ○ Early referral to primary team (urosurgery) 6. Perform the primary adjunct. - ABG analysis - ECG monitoring - Trauma series - Chest + pelvic x ray.+ lateral cervical spine - FAST scan. - CT brain and abdomen.