CASE STUDY
Mr Tony Block is a 52 year old man who presents to the emergency department (ED) after having a motor bike accident (MBA) 1 hour ago. Mr. Block is alert when the paramedics arrived at the accident scene. Mr. Block is complaining of severe pain (10/10) to his left rib area and abdomen, he states to the paramedics he lost control of the motorbike whilst turning the corner and came off the bike hitting his abdomen on the handle bars.
Mr. Block was treated at the accident site by the paramedics and arrives to the ED at 0950hrs on 4 February 2015 with the following:
PRIMARY SURVEY
AIRWAY: Awake and alert, lying in a supine position with rigid cervical collar insitu. Has no upper airway noises and facial abrasions are noted.
BREATHING: RR 26 breaths/min; shallow. He is receiving 10L/min 02 via a Hudson mask. His Sp02 is 95%. On auscultation decreased air entry left base.
CIRCULATION: HR 108 bpm (regular), monitoring in sinus rhythm. Heart sounds normal. BP 90/55mmHg, patient is cool to touch. Temp 35.7°C.
DISABILITY: GCS 15/15. Equal power and movement in all limbs. Pupils equal reactive to light. Equal power 6/6.
EXPOSURE: Cut clothes to remove. Extensive bruising noted over the abdominal ULQ and left lateral thoracic region.Log roll- no obvious step, anal tone normal.
FLUIDS: I.V. Hartmann’s running via I.V. 16g cannula, right cubital fossa.Bloods taken from 2nd cannula, left cubital fossa.
GLUCOSE: BGL 4.4 mmol/L
AMPLE ASSESSMENT
A – Allergies: none
M – Medications: regular paracetamol, last taken x 2 06.30hrs
P – Past medical history(PMHx): Chronic lower back pain. Minor injuriesaffecting mainly knee joints playing footie.
L – Last Ate: cereal and tea 06.30hrs (NB. LMP-females)
E – Events (This is usually the MIST)
MIST ASSESSMENT
M: mechanism of injury- MBA accident. Estimated speed of the rider at time of the accident 35km/hr. Rider lost control of the motorbike whilst turning a corner.
I: injuries- extensive bruising noted over abdominal LUQ. Suspected fractured ribs on the left side (patient states he has 10/10 pain over his thoracic region). Facial abrasions.
S: signs (vital signs on scene and during transport)- GCS 15/15, HR-105-136bpm, BP-90-120mm/Hg (systolic), RR-20-30bpm.
T: treatment initiated- I.V.F (Hartmann’s), I.V. 2.5mg morphine x 2. Last dose 09.30hrs
SECONDARY SURVEY
Head to toe assessment normal
Provisional diagnosis: Patient admitted with suspected blunt abdominal injury, ?fractured ribs ( Left side), +/- Left lung contusions secondary to a MBA (low speed).
Pre-hospital treatment by paramedics:
- C-spine immobilisation
- I.V. cannula x 2 (large bore 16g cannula right and left cubital fossa)
- 02 therapy 10L/min via non-rebreathing mask
- I.V. morphine 2.5mg x 2
Initial management in the ED:
- Primary survey
- MIST assessment
- Urgent CXR/AXR
- FAST (Focused Assessment with Sonography for Trauma) scan
- ECG
- Blood tests (FBC, EUC, ABG, Coag’s-APTT, PT, INR)
- I.V. 5mg morphine & I.V. 10mg metoclopramide
- Trauma series CT scans (may be referred to as Pan CT scan-head, neck, chest, and abdomen/pelvis, spine.
Investigation results:
Focused Assessment with Sonography in Trauma(FAST) – positive
CXR: Multiple left rib fractures; lung contusions
AXR: Fluid noted in the peritoneal cavity
Abdominal CT scan: Moderate (between 400-500mL of fluid) in perisplenic region. Grade IV Splenic laceration involving hilar vessels.
ECG: Sinus Rhythm
Full blood count (FBC)
| FBC | Result | Normal range |
| Haemoglobin (Hb) | 90 g/L | 130-180 g/L |
| Red cell count (RCC) | 3.2 x 1012/L | 4.5-6.5 1012/L |
| Packed cell volume (PCV) | 0.285 | 0.40-0.54 |
| Total white cell count (WCC) | 10.8 x 109/L | 4.0-10.0 x 109/L |
| Platelets | 290 x 10 9/L | 150-400 x 109/L |
Electrolytes, urea & creatinine (EUC)
| EUC | Result | Normal range |
| Na+ | 140 mmol/L | 135-145mmol/L |
| K+ | 3.9 mmol/L | 3.8-4.9mmol/L |
| Cl– | 101 mmol/L | 95-110 mmol/L |
| Mg2+ | 0.8 mmol/L | 0.8-1.0 mmol/L |
| Urea | 4.6 mmol/L | 3.0-8.0 mmol/L |
| Creatinine | 132 µmol/L | 60-120 µmol/L |
Coagulation (‘Coags’)
| ‘Coags’ | Result | Normal range |
| APTT | 38 sec | 25-35 seconds |
| PT | 15 sec | 11-15 seconds |
| INR | 1.2 | 2.0-3.0 |
Arterial blood gases (ABG) on 10L/min O2 via Hudson Mask
| ABGs | Result | Normal range |
| pH | 7.39 | 7.36-7.44 |
| PaO2 | 75 mmHg | 80-100 mmHg |
| PaCO2 | 40 mmHg | 35-45 mmHg |
| HCO3 | 24 mmol/L | 22-32 mmol/L |
| Lactate | 0.8 mmol/L | 0.3-0.8 mmol/L |
Diagnosis: Grade IV splenic laceration; moderate intra-peritoneal haemorrhage (approx..500mL); multiple left rib fractures; left lung contusions.
Plan:
- Trauma team present
- For urgent angioembolisation-contact radiology
- ICU admission-contact ICU consultant
- Group &crossmatch 3 units of packed red cells
- I.V. 1gm cefalotin stat.
- I.V. morphine infusion titrated to patient’s pain score (dose between 1-2.5mg/hr)
- Booster Tet-Tox(TM)
Mr Block is taken to radiology for an urgent splenic artery angioembolisation and CT scans.
Q1. a) Prioritise and justify the care of the patient using the primary survey including a possible pathogenesis
- b) Based on your assessment select ONE (1) appropriate nursing strategy including your rationale
Q 2. a) Critically analyse TWO (2) diagnostic results, and relate to the underlying pathogenesis.
Q 3. Discuss a) the mode of action of ONE drug, relating to the underlying pathogenesis and (I think we can use I.V. 1gm cefalotin stat. as mentioned above)
- b) how you would evaluate the therapeutic effect of the drug and
- c) explains how you would monitor for and respond to any adverse effects of the drug.
125 words each question please.
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