Linh Hoang

Surgery Pd 11 & 12

Case 3

32 y/o female who falls from her bicycle in front of an oncoming car. She is disoriented, and has tire tracks
across both thighs.

I would ensure that the trauma team has been activated. Then I would first assess the patients breathing
and hemodynamic status and ensure that airway passages are non-obstructed and that she has sufficient
perfusion to all vital organs. I would then ensure all bleeding has been controlled and start NS as necessary if
the patient is hemodynamically unstable, with consideration for blood transfusion. Following stabilization, I
would order EKG, CBC, CMP, ABGs, BUN/Cr, blood type and cross-match. Because she is a female of child-
bearing age, I would also consider a b-HCG. I would also conduct ultrasound of the abdomen and pelvis
according to the FAST procedure. If the patient is hemodynamically stable, I would consider xrays of the
chest, abdomen, pelvis, and bilateral lower extremities as well as CT abdomen and pelvis with contrast.

I would elicit as much history as possible either from the patient or any accompanying parties regarding
exactly where the vehicle struck her and at what speed. I would also attempt to elicit personal medical
history, any current meds, allergies, and family history of bleeding disorders. I would then conduct a brief
PE, first by assessing the patients GCS score. The GCS score which assesses consciousness in a patient
following traumatic brain injury. In blunt trauma it can be used to assess for abdominal injury. I would assess
for adequate perfusion to extremities, cardiovascular rhythm and rate. I would then auscultate the lungs for
possible collapse or pleural effusion or rib fracture. I would examine the abdomen for any signs of trauma
and exquisite tenderness which may indicate rupture. I would then conduct a brief neuro eval, specifically
focusing on the lower extremities.

Organs that may possibly be damaged include the spleen, liver, kidney, and bowels, which are commonly
injured in abdominal trauma. I would also consider injury to the lung and heart depending on the patients
impact with the vehicle. Possible vessel damage include the aorta, superior and inferior mesenteric arteries,
femoral artery, and popliteal artery. If there are indications of organ damage with bleeding into the
peritoneal cavity, I would consider diagnostic peritoneal lavage to assess for hemoperitoneum and consider
exploratory laparotomy for repair of damaged organs. I would consult Vascular Surgery for repair of any
major vessels.

For further management of the patient after she has been stabilized, I would consult Ortho for repair of
fractures Tire tracks across the patients thigh may indicate possible long bone fracture which can result in
fat embolization, and therefore the patient must be carefully monitored for symptoms of embolization. It
can also indicate major crush injury due to ischemia reperfusion of a limb. Muscle injury can cause
potassium, phosphate, myoglobin, creatine kinase, and urate to leak into the circulation. This can lead to
metabolic acidosis and acute kidney injury. There must also be consideration for rhabdomyolysis. I would
also consult Neuro, PT, and Medicine for future management of the patient.