GP Emergency Trauma Assessment Note

Emergency Trauma Assessment

34M BIBA High-speed MBA with right chest wall trauma and open right tibial fracture.

Pre-Arrival

• Personal Protective Equipment (PPE): Gowns, gloves, eye protection, and lead aprons worn by all team members.
• EMS Notification: 14:10 AEDT - Ambulance Victoria notified ED of 34M involved in high-speed MBA vs car. Field vitals: HR 125 bpm, BP 95/60 mmHg, RR 28 bpm, SpO2 92 % on 15 L/min NRB. Interventions: C-spine collar, pelvic binder, right lower limb splint, 18G IV x 2, fentanyl 50 mcg IV, 500 mL 0.9% NaCl IV bolus.
• Mechanism of Injury: Blunt trauma. Ejected 5 m from motorcycle at approx. 70 km/h after T-bone collision with sedan. Helmet intact with heavyvisor scoring; nil other fatalities at scene.
• Trauma Activation Criteria: Level I activation due to hypotension in field (SBP < 100 mmHg) and high-risk mechanism (motorcycle ejection > 30 km/h).

Arrival

• Time of Patient Arrival: 14:22 AEDT
• Trauma Team Activation Time: 14:12 AEDT
• Team Members Present: Dr. S. Patel (GP/ED VMO), Dr. M. Vance (Surgical Reg), RN J. Smith, RN K. Lee, Radiographer T. Nguyen.
• EMS Hand-off
  • Time of Handoff Completion: 14:25 AEDT
  • Key Findings from EMS Report: 34M ejected from motorcycle, helmeted. Transient hypotension in field, responded partially to 500 mL crystalloid. Complaining of severe R chest and R leg pain.
• Immediate Life Threats Noted: Suspected right tension pneumothorax / haemopneumothorax with hypoxia and tachycardia at 14:25 AEDT.

Primary Survey (ABCDE Assessment)

Vital Signs

RR: 26 bpm, SpO2:94 %, HR: 118 bpm, BP: 102/68 mmHg (MAP: 79 mmHg ), T: 36.1 °C, GCS: 14 (E: 4, V: 4, M: 6)

Central Capillary Refill Time: 3 seconds

Airway

• Patent: Patent, no blood, vomit, or foreign body obstruction.
• Verbal Response: Confused (asking repeated questions), speaking in short sentences, no stridor or hoarseness.
• Airway Interventions: Yankauer suctioning performed at 14:26 AEDT (minimal clear secretions); maintained on high-flow O2.

Breathing

• Chest Wall Examination: Asymmetrical expansion (reduced on right), significant bruising and surgical emphysema palpable over right lateral ribs 4–8.
• Trachea Position & JVD: Trachea central, nil JVD noted.
• Breath Sounds: Absent on right side, vesicular on left.
• Oxygenation/Ventilation: SpO2 94 % on 15 L/min O2 via NRB mask; EtCO2 38 mmHg via nasal cannula monitor.

Circulation

• External Bleeding: Moderate venous oozing from 4 cm open wound over right anterior mid-shin; controlled with direct sterile pressure dressing at 14:28 AEDT.
• Internal Bleeding Suspicion: E-FAST at 14:30 AEDT positive for right haemopneumothorax (absent lung sliding, fluid above diaphragm); negative pericardial and abdominal windows.
• Blood Pressure & Pulses: BP 102/68 mmHg. Strong bilateral radial pulses, strong L dorsalis pedis pulse, weak but palpable R dorsalis pedis pulse.
• Pelvic Stability & Intervention: Pelvic binder in situ applied by EMS at 13:55 AEDT due to mechanism; pelvis not sprung on exam.

Disability (Neurologic Status & Cervical Spine Status)

• Pupil Examination: PEARL bilat (3 mm)

• Extremity Movement: Moving UL and L LL with 5/5 power; R LL movement limited by pain and fracture, able to wiggle R toes.

• Cervical Spine (Status and precautions taken): Cx Spine precautions in place; inline immobilisation maintained.

  • Collar: Yes, Stifneck rigid collar in situ, precautions instituted at 13:50 AEDT by EMS.

• Exposure:

  • Complete Undressing: Clothes removed completely via trauma shears at 14:27 AEDT.
  • Hypothermia Prevention: Bair Hugger forced-air warmer applied and warmed IV fluids commenced at 14:32 AEDT.
  • Log Roll for Back Assessment: Log roll performed at 14:40 AEDT; nil thoracic/lumbar step-offs, mild bruising over R flank, intact perianal sensation (nil saddle anaesthesia).

Secondary Survey

• AMPLE History:

  • Allergies: NKDA
  • Medications: Salbutamol (Ventolin®) 100 mcg PRN INH; nil anticoagulants, insulin, or steroids.
  • Past Medical History: Mild asthma.
  • Last Meal: 12:30 AEDT (chicken sandwich and coffee).
  • Events Leading to Injury: Patient travelling through intersection on green light when struck on right side by turning vehicle.

• Physical Exam:

  • Head & Face: No scalp lacerations, facial bones stable, nil hemotympanum, nil septal hematoma, symmetrical facial movement, nil Battle sign.
  • Cervical Spine: Mild midline tenderness at C5–C6; CT Cx spine required.
  • Thorax: Tenderness and crepitus over R ribs 4–8, breath sounds improved on R post-ICC insertion, HSDNM.
  • Abdomen/Pelvis: Soft, mild RUQ tenderness, nil guarding or rebound, nil seat-belt/handlebar bruising, pelvic binder in situ.
  • Extremities: UL bilateral neurovascularly intact. L LL NAD. R LL gross deformity mid-shaft tibia with 4 cm puncture wound (Gustilo-Anderson Grade II), R DP and PT pulses 1+, capillary refill 2 seconds, gross sensation intact across all limbs.
  • Back: No spinous-process tenderness or step-offs, 6 x 6 cm abrasion over R posterior thorax.

Assessment & Plan

• Summary of Findings* 34M post high-speed MBA with R haemopneumothorax, multiple R rib fractures, and open R mid-shaft tibia/fibula fracture. GCS 14 (improved to 15 at 14:45 AEDT), haemodynamically stabilising post-ICC and fluid resuscitation (BP 115/75 mmHg, HR 98 bpm at 14:50 AEDT).
• Interventions Performed:
  • 14:32 AEDT: 28Fr R intercostal catheter (ICC) inserted in 5th intercostal space mid-axillary line under local anaesthetic (lidocaine 1% 10 mL subcut); 350 mL blood and air drained, underwater seal drain bubbling and swinging.
  • 14:35 AEDT: Tranexamic acid 1 g IV over 10 mins, cefazolin 2 g IV stat, ADT booster 0.5 mL IM stat.
  • 14:38 AEDT: Morphine 5 mg IV bolus + metoclopramide (Maxolon®) 10 mg IV stat.
  • 14:42 AEDT: 1 unit pRBC commenced via rapid infuser; open R leg wound irrigated with saline and dressed with betadine-soaked gauze and plaster backslab.
• Pending Procedures & Investigations:
  • Trauma pan-CT (CT Brain, C-spine, Chest, Abdo/Pelvis) and R tib/fib X-ray.
  • FBE, UEC, LFT, Lipase, Coags, VBG, Group & Hold, Crossmatch 4 units.
  • Secondary wound washout and formal reduction in OT.
• Disposition: Transfer to CT scanner with trauma team escort at 15:00 AEDT, then direct to Operating Theatre (OT) and surgical HDU admission.
• Consultations: Trauma Surgery (Dr. M. Vance at bedside), Orthopaedic Surgery (paged at 14:45 AEDT, awaiting review in ED/CT).