Trauma Note

Identification

• Marcus Vance is a 42-year-old male.

Mechanism of Injury

• Restrained driver involved in a high-speed T-bone motor vehicle collision on the driver's side.

Prehospital Course

• Collision occurred at 14:15; prolonged extrication of 20 min required.
• Patient was ambulatory on scene briefly before complaining of severe left-sided chest and abdominal pain.
• EHS placed C-spine collar, established 18G IV in right AC, and administered fentanyl 50 mcg IV at 14:40 for pain.
• Vital signs en route: HR 115 bpm, BP 105/70 mmHg, RR 24/min, SpO2 95 % on room air.

Primary Survey

• Alert, diaphoretic, in moderate painful distress.
• T 36.8 °C, HR 118 bpm, BP 98/64 mmHg, RR 26/min, SpO2 94 % on RA (improved to 99 % on 4 L NP).
• Airway patent, speaking in full sentences, no blood or vomit.
• Asymmetric chest rise with decreased air entry and subcutaneous emphysema over the left lateral hemithorax; tachypneic.
• Skin cool and clammy, radial pulses 2+ bilaterally, no active external blood extravasation.
• GCS 15 (E4, V5, M6), pupils 3 mm equal and reactive to light, moving all four extremities with intact sensation.
• eFAST positive for trace free fluid in the splenorenal recess, absent lung sliding on the left anterior chest, negative for pericardial effusion.

Secondary Survey

• 3 cm superficial laceration to left forehead, no battle sign or hemotympanum.
• Midline C-spine tenderness at C5-C6; trachea midline.
• Tachycardic, normal S1/S2, no murmurs.
• Decreased breath sounds throughout the left lung field; right lung clear.
• Left lateral chest wall tenderness, crepitus, and ecchymosis; positive seatbelt sign across left chest.
• LUQ abdominal tenderness with voluntary guarding, positive seatbelt sign across lower abdomen, no rigidity.
• Pelvis stable to anteroposterior and lateral compression, no tenderness.
• No perineal ecchymosis or blood at the urethral meatus.
• 4 cm laceration over left anterior tibia with minimal oozing, no gross bony deformities.
• Log-rolled: no thoracic or lumbar spinal step-offs or tenderness, no flank ecchymosis.

Resuscitation

• Placed on cardiac monitor and 4 L O2 via nasal prongs at 14:55.
• Second 16G IV established in left AC; 1 L Ringer's lactate bolus initiated at 15:00 for hypotension and tachycardia.
• Tranexamic acid 1 g IV infused over 10 min at 15:05.
• Fentanyl 50 mcg IV given at 15:10 for ongoing chest wall pain.
• Left 28 Fr chest tube inserted at 15:15 for traumatic pneumothorax, with immediate rush of air and 150 mL blood return.
• Tetanus toxoid (Tdap) 0.5 mL IM administered at 15:25.
• Cefazolin 2 g IV administered at 15:30 prior to laceration repair.

Past Medical History

• Hypertension.
• Laparoscopic appendectomy (2012).

Home Medications

• Ramipril (Altace®) 5 mg PO daily.

Allergies

• Penicillin (rash).

Immunizations

• Last tetanus booster > 10 years ago; updated in ED today.

Social History

• Non-smoker, social alcohol use (2–3 drinks/week), works as a civil engineer, lives in a house with his wife and two children.

Investigations

• Labs: Hb 128 g/L, WBC 14.2 x 10^9/L, Plt 245 x 10^9/L, Na 139 mmol/L, K 4.1 mmol/L, Cr 88 umol/L, lactate 2.8 mmol/L, EtOH < 2 mmol/L, venous blood gas pH 7.34, pCO2 38 mmHg, HCO3 21 mmol/L.
• ECG: Sinus tachycardia at 112 bpm, normal axis, no acute ST-T wave changes.
• Portable CXR (post-chest tube): Left chest tube in good position, resolved left pneumothorax, minimally displaced fractures of left ribs 5–7.
• CT Head/C-spine: No acute intracranial hemorrhage or calvarial fracture; no C-spine fracture or malalignment.
• CT Chest/Abdomen/Pelvis (with IV contrast): Moderate left hemopneumothorax with chest tube in situ, displaced fractures of left lateral ribs 5, 6, and 7; Grade II splenic laceration with small perisplenic hematoma, no active contrast blush.

Consultants

• 16:10 – Spoke with Dr. S. Chen (General Surgery / Trauma consultant), who reviewed the CT images and examined the patient; agreed to admit to the Trauma service for non-operative management of the Grade II splenic injury, serial hemoglobin checks, and chest tube management.

Reassessments

• 15:45 – Post-chest tube and 1 L fluid bolus: HR improved to 92 bpm, BP 118/76 mmHg, SpO2 98 % on 2 L NP. Patient reports improved dyspnea. Chest tube draining serosanguinous fluid with no air leak.
• 16:30 – Vital signs remain stable (HR 88 bpm, BP 122/78 mmHg). Repeat eFAST shows stable small volume fluid in LUQ. C-spine collar removed after negative CT and clinical reassessment showing improved neck range of motion without paresthesias.

Procedures

• 15:15 – Left tube thoracostomy: Timeout performed. Left 5th intercostal space at mid-axillary line prepped with chlorhexidine and draped in sterile fashion. Local anesthesia achieved with 10 mL of lidocaine 1 % (Xylocaine®). 3 cm incision made, blunt dissection over superior rib margin into pleura; finger sweep confirmed pleural space and no adhesions. 28 Fr chest tube inserted posteriorly and apically, connected to Pleur-evac on -20 cmH2O suction. Secured with 0-silk suture and occlusive dressing. Post-procedure CXR confirmed placement.
• 16:00 – Left forehead and pretibial laceration repairs: Wounds irrigated copiously with sterile normal saline. Anesthetized with total 8 mL lidocaine 1 % with epinephrine. Forehead closed with five interrupted 5-0 nylon sutures; pretibial laceration closed with six interrupted 4-0 nylon sutures. Polysporin applied.

Summary of Injuries

• Left traumatic hemopneumothorax.
• Left displaced rib fractures (ribs 5, 6, and 7).
• Grade II splenic laceration.
• Left forehead laceration (3 cm).
• Left pretibial laceration (4 cm).

Impression / Plan

• 42M post-MVC with left hemopneumothorax (status post chest tube), left rib fractures (5–7), Grade II splenic laceration, and multiple lacerations, currently hemodynamically stable after initial resuscitation.
• Admit to Trauma Service under Dr. S. Chen.
• NPO, IV maintenance fluids with normal saline at 100 mL/h, strict bedrest.
• Serial Hb and lactate q6h x 24 h; group and screen on hold.
• Multimodal analgesia: paracetamol (acetaminophen, Tylenol®) 1,000 mg PO/IV q6h scheduled, hydromorphone (Dilaudid®) 0.5–1 mg IV q2h PRN, incentivo spirometry.
• Suture removal in 5 days for forehead and 10–14 days for pretibial wound; monitor for signs of infection after discharge.

Resuscitation Time

• 14:55 to 15:45
• Total time: 50 minutes

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