TRAUMA

 

 

History of the Patient

Chief complaints and History of presenting illness

An approximately 45-year-old male with an estimated weight of 67kg who is reported to be unconsciously found with multiple stab wounds to the chest, arms, and back. He is lying prone in a pool of blood, and the singlet and underpants he is wearing are drenched in blood. Upon primary assessment, he is noted to be drowsy, pale, confused, and cool to touch. Exposure of patient shows 20 stab wounds to the chest, back and arms. The wounds are lacerations approximately 3-5cm deep and lengths varying from 5cm-10cm. The estimated time of injury is 2300 hours night before, which is 8.5 hours ago. No other injuries have been found, and no drug paraphernalia is present at the scene.

 

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Past medical, Medication history & Social history

No current use of medications is reported, and the patient has been sober for a month.  Also, no known drugs or food allergies are reported. Family and social history were not available.

Vital signs and other Examination findings

The body temperature, being 35.5°C, is abnormally low as average normal core temperature is considered to be between 36.6°C and 37.4°C. Pulse rate measured at the brachial artery was 132 beats/ minute which is high as it should range between 50 and 80 in adults. Above 100 is considered tachycardia. It was also regular, weak and thready as opposed to being strong and of a constant volume. The radial pulse was absent which is abnormal as well. Normal respiration rate in adults is 16-20 breaths/ minute Therefore a rate of 32 breathes/ minute is highly increased and coupled to respiration been shallow, the patient is in respiratory distress. The patient was hypotensive with blood pressure measured at 70/45mmHg- the numerator and denominator denote systolic and diastolic pressures respectively. Systolic pressure range is 90-140 while the diastolic range is 60-90 (Charbek, 2015).

The above four are the standard primary vital signs; however, other investigations are also done and may be included as part of vital signs. They include SpO2 (partial saturation of oxygen) of 92%, pupils being bilaterally equally reactive to light, chest auscultation with equal air entry with no adventitious sounds and blood glucose levels of 4.2mmol/L which are all normal (Hall, 2015). A pain score of 4/10 is abnormal and can be attributed to the stab sites.

The skin is cool, pale and diaphoretic instead of warm and dry. Also central capillary refill of 4 seconds instead of the immediate return of capillary refill, sinus tachycardia rate of 132 on ECG (Electrocardiogram), and increased respiratory effort with an increased rate of respiration (respiratory distress). There are decreased levels of consciousness as AVPU scale is at V with the patient opening his eyes to voice prompting confirmed by a GCS (Glasgow Coma scale) score of 13/15. All these findings added to those on the primary vital signs: that is, tachycardia, hypotension, hypothermia and respiratory distress are all signs of hypovolemic shock (Brunicardi et al., 2009).

Preliminary Diagnosis & Epidemiology

The provisional diagnosis tying together the history and the primary assessment is a hypovolaemic shock due to haemorrhage. Hypovolaemia is the major form of shock and is to an extent a component of all the other forms of shock which are cardiogenic, obstructive, distributive and endocrine shock (Williams, O’Connell, & McCasksie, 2018).

Trauma is the chief cause of death in the first 40 years of life in the developed countries. Haemorrhage is the main cause of trauma-related deaths in the military setting and is the second major cause of death (after traumatic brain injury) in the civilian setting (Kirkman & Watts, 2014).

Haemorrhage, in this case, could result from vascular injury of the brachial or ulnar or radial arteries, massive haemothorax or haemoperitoneum as well as external blood loss from the stab wounds. Tension pneumothorax, open pneumothorax and cardiac tamponade complete the list of differential diagnoses.

Pathophysiology

Shock is a state of low tissue perfusion that is inadequate for ordinary cell metabolism. With the inadequate delivery of oxygen and glucose cell switch from aerobic to anaerobic metabolism which causes accumulation of lactic acid to produce systemic metabolic acidosis. The body response to shock produces the classical signs and symptoms as in the patient in this case. In the cardiovascular system decrease in preload and afterload causes a compensatory baroreceptor response resulting in increased sympathetic activity and catecholamine release that result in tachycardia and systemic vasoconstriction responsible for the cold peripheries. Metabolic acidosis and increased sympathetic response result in an increased respiratory rate and minute ventilation to increase excretion of carbon dioxide (Williams, O’Connell, & McCasksie, 2018).

With shock progressing cardiovascular and endocrine response decrease flow to non-essential organs to preserve circulation to the brain, lungs, kidneys and the heart itself. In compensated shock, the body can sustain central blood volume and preserve flow to essential organs. Further loss of circulating volume overloads the body’s compensatory mechanism so that there is progressive renal, respiratory and cardiovascular decompensation. Loss of around 15% of circulating blood volume is within usual compensatory mechanisms, and blood pressure is usually well maintained. It only falls after 30-40% of circulating volume has been lost. This is what happened in the case above: 4 hours before the patient was normotensive with a blood pressure of 110/65mmHg, but with continued loss 4.5 hours later the blood pressure dropped to 70/45mmHg. The hypotension, profound tachycardia, zero urine output and unconscious patients with laboured breathing characterise severe shock (Williams, O’Connell, & McCasksie, 2018).

Investigations and Clinical Treatment (Management)

Management of this particular patient is done following the Advanced Trauma Life Support (ATLS) system that identifies and treats life-threatening conditions according to priority in the order of ABCDE in primary survey.

  1. This stand for Airway protection and cervical spine protection. Patency of airway is assessed by talking to the patient of which if the patient talks patency is confirmed. Considering the stab wounds at the back, the spinal cord is protected using a rigid collar such as the Philadelphia collar and the patient is immobilised by being strapped to a spine board with head support. This is done until spine injury is excluded on arrival to the hospital (McLatchie, Borley, & Chikwe, 2013).
  2. It stands for Breathing and ventilation. High-flow oxygen (40-60%) using a non-rebreathing reservoir is administered at a flow rate of 4-10l/min. The chest is then inspected, palpated, percussed and ausculted to identify life-threatening conditions. Tension pneumothorax is treated with immediate decompression by inserting a 12G cannula in the second intercostals space at the mid-clavicular line; open pneumothorax occluded with three-sided dressing, massive haemothorax with decompression buy inserting a wide bore chest drain and cardiac tamponade using an ultrasound-guided pericardiocentesis (McLatchie, Borley, & Chikwe, 2013).
  3. This is for Circulation and haemorrhage control and will be the area of focus in this particular patient. First is to control external bleeding by applying direct pressure using sterile gauze which can be secured to the body surface using adhesive tape around the torso. Next is obtaining intravenous access using two 12G cannulae on both forearms, take blood samples for cross-matching, full haemogram, clotting, urea, and electrolytes and then commence bolus of warmed Ringer’s lactate solution one of 500ml on each arm. This is done in the shortest time possible and if the blood pressure and pulse do not respond can be repeated once more after which unmatched type-specific blood (O-ve) should be given. The endpoint for resuscitations is a systolic blood pressure of more than 90mmHg (McLatchie, Borley, & Chikwe, 2013).
  4. Stands for Disability based on the AVPU scale and Glasgow Coma Scale.
  5. Stands for Exposure and Environment control where the patient is undressed for thorough examination while preventing hypothermia by covering with warm blankets or other warming devices (McLatchie, Borley, & Chikwe, 2013).

Transport

In ATLS effort is effort is made to minimise scene time and emphasise immediate transport to the nearest appropriate facility, this case the state trauma centre that is 20 minutes away. In-line stabilisation is maintained while in transit in the ambulance, which is the transport medium of choice.

 

References

Baker, C. R., Reese, G., & Teo, J. T. (2010). Rapid Surgery. Chichester: Wile- Blackwell.

Brunicardi, F. C., Anderson, D. K., Billiar, T. R., Dunn, L. D., Hunter, J. G., Pollock, R. E., et al. (2009). Schwartz’s Principles of Surgery. New York: McGraw-Hill Education.

Charbek, E. (2015, August 27). Normal Vital Signs. Retrieved March 15, 2018, from Medscape: http://emedicine.medscape.com/article/2172054-overview#a1

Hall, J. E. (2015). Guyton and Hall Textbook of Medical Physiology. London: Elsevier Health Sciences.

Kirkman, E., & Watts, S. (2014). Haemodynamic changes in trauma. British Journal of Anaesthesia , 266-275.

McLatchie, G., Borley, N., & Chikwe, J. (2013). Oxford Handbook of Clinical Surgery. Oxford: Oxford University Press.

Williams, N. S., O’Connell, P. R., & McCasksie, A. (2018). Bailey & Love Short Practice of Surgery. Portland: Taylor & Francis Inc.

 

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