1) Mr. AZ, a 21-year-old man, was brought to the ED after a motorbike accident with open fractures of his left forearm bones and bilateral lung contusions. 2) Secondary surveys found additional injuries including possible skull fracture and closed fractures of his right wrist bone. 3) The patient was resuscitated for hypovolemic shock and underwent wound care, imaging, and splinting while awaiting stabilization for orthopedic surgery.

1. ED Case Discussion - Trauma
Presented by: Hakimah Khani Binti Suhaimi
Supervised by: Dr Farina (ED Sungai Buloh)

2. Chief Complaint
• Mr. AZ, a 21 year-old Malay
gentleman was brought to the
ED on the 18th October due to
an MVA.

3. History
• Mr. AZ, a 21 year-old Malay gentleman was brought in
by ambulance at around 11pm due to an MVA.
• According to MA, it was a motorbike-vs-car accident.
• Patient was the rider on the motorbike.
• Exact mechanism of injury was unknown.
• Patient was unable to recall anything, not even what he
was driving.

4. History (contd.)
Post-trauma, injuries sustained:
• Left forearm - pain and bleeding
• Upper chest abrasions - pain and bleeding
• No LOC, no headache
• No ENT bleed
• No SOB
• No abdominal pain, no nausea/vomiting

5. History (contd.)
During the process of transfer,
Patient was put on spinal board, and cervical collar was
applied.
He was then managed by resusc. team in red zone.

6. Past Medical History
Nil
Drugs & Allergies
Nil

7. Assessment (Primary Survey)
Upon arrival at ED Resusc. HSB
A: Patient spoke in full sentences, no stridor, airway patent, no obstruction.
Cervical collar was applied to him.
No tracheal shift.
B: Breathing spontaneously; tachypnoeic; RR:28 with SpO2:99% on
HFM 15L/min
Equal chest rise bilaterally. No paradoxical movement.
Upper chest abrasions, no deformities, no open wound.
Reduced air entry at lower zone bilaterally.
C: CRT < 2 sec, PR:100; good pulse volume, warm peripheries. No obvious
active bleeding elsewhere. 2 large bore IV lines were set, attached to 500ml
NS.
D: GCS:14/15, E4V4M6, Pupil Bilateral Reactive:4/4

8. Assessment (Secondary
Survey)
GCS:14/15, E4V4M6, Pupil Bilateral Reactive:4/4
Vital Signs:
• Pulse rate : 100 bpm
• BP : 176/83 mmHg
• Respiration rate : 28 /min
• Temperature : 37 °C
• SPO2 : 100 %

9. Assessment (Secondary Survey)
(contd.)
Head-to-toe examination:
• Head: No lacerations/contusion, no ENT bleed, no swollen eyes, presence
of abrasion at chin area
• Neck: Minor abrasion over left shoulder and neck, no distended jugular
veins, no cervical tenderness, no tracheal deviation
• Chest: Negative chest spring, no palpable crepitus over chest wall. Cvs:
Dual rhythm, no murmur
• Abdomen: No bruises, distension, bleeding. Soft, non tender. Normal bowel
sounds

10. Assessment (Secondary Survey)
(contd.)
Head-to-toe examination:
• Pelvic Spring: Negative
• No scrotal hematoma
• Log roll: No evidence of spine tenderness/swelling/deformity
• PR: Normal anal tone, no bleeding
• Lower extremities: No bleeding, swelling or deformity
• Upper extremities: Open wound exposing bone in left forearm and
contused muscle, no active bleeding. Spo2 on all fingers: 98-100%. Limb
immobilization by backslab was done.
• All peripheral pulses are palpable, equal bilaterally, good volume
• Fast Scan at 11pm: No free fluid with sliding sign present

11. Impression
• Open fracture left radius and
closed fracture of left ulna
• Bilateral lung contusion
• Possible skull fracture /
intracranial bleed

12. Management
Vital signs were reevaluated every 5 mins
Put on CBD for strict I/O Chart
Total intake: 2000ml,
Total output: 0ml
Patient was kept NBM
IM ATT given

13. Management
Medications:
-IV Morphine 2.5mg stat and titrated accordingly
-IV Zinacef 1.5mg stat
-IV Flagyl 500mg stat
FBC: Hb:16.3/WBC:11.1(Lymp:38.9/Gran:57.5)HCT:51.4/PLT:345
ABG on HFM: pH:7.397/pCO2:30/pO2:57.8/HCO3:20.1/BE:-5.9
Coagulation profile, RP, GXM 4 pint packed cell were ordered

14. Management
Wound irrigation over chin, neck and chest was done
Radiological investigations were done
• CXR & Pelvic X-Ray
• Bilateral Radius & Ulnar X-Ray
• CT Brain & Lateral c-spine

15. - CXR:
bilateral lungs
contusion,
no rib fracture,
no pneumothorax,
no flial segment

16. Left Radius & Ulnar X-Ray:
- fracture @proximal 1/3rd
and distal end of left
radius
- fracture of midshaft of left
ulna
Mx: Backslab of left upper
limb

17. Left Radius & Ulnar X-Ray:
- fracture of right radial
styloid
Mx: Above-elbow backslab of
right upper limb

18. - CT cervical
Right pedicle and
transverse foramen
fracture. In the absence of
associated soft tissue
injury, these are probably
old fracture

19. - Pelvic X-Ray
No abnormalities
detected.

20. - CT brain
No intracranial bleed.
No focal brain parenchymal
lesion.
No midline shift or mass effect.
Normal grey-white matter
differentiation.
Ventricles & CSF-spaces are
normal.
Visualised paranasal sinuses are
clear

21. Impression
1)open fracture @proximal 1/3rd
and distal end of left radius and
frcature of midshaft of left ulna
2)closed fracture of right radial
styloid
3)bilateral lung contusion

22. Progress
@ 1.30am
• In spite of 2 liter fluids transfused, BP was still unstable;
• dropped to 87/46mmHg, RR 32bpm, PR 101bpm
~ Hypovolemic Shock Class III
•  resuscitated with IV 1 pint EO blood  125/96mmHg

23. Disposition
• Refer to orthopaedics &
surgical team once patient is
hemodynamically stable.