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Case Study #2: MVC

Case Study #3
by

Robert Baginski

on 17 May 2017

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Transcript of Case Study #2: MVC

History of Present Illness:
Chief Complaint:
Your patient and her husband are on the way back from the airport after renewing their wedding vows in the "Taco Bell Wedding Chapel" in Las Vegas. You are working an evening shift when you hear the EMS radio report that EMS is on scene at a MVC. The patient's husband was wearing his seatbelt and is uninjured. However, your patient, a 33 year old female, was not restrained and is brought into the ED by EMS.
Radiology
X-Rays
Ancillary Studies
Hematology
Medical History:
PMH
:
Hypertension
Diabetes Type II
Iron deficiency anemia
Pre-eclampsia (resolved)
No surgical history
No traumatic history

Meds
:
FeSO4
Metformin
HTN med

Allergies
: NKDA
"The Case of the Irresistible Force vs. the Immovable Object"
Case #2
Other
Studies

Medical History
HPI
P.E.
Physical Exam
Coags
Urinalysis
Chemistries
Liver Function Tests
Cardiac Enzymes
Toxicology
AST: 155
ALT:

245
Total Bili: 1.1
Direct Bili:
0.3
Ammonia: 5
CK: 255
CKMB: 9.7

Troponin I: 0.11
PT: 15.1
PTT: 42
INR: 1.6
ETOH: <10
Urine Tox: neg
APAP: <2.0
ASA: 0
CT Scans
Ultrasounds
MRI
C-Spine
Radiology
Differential
Diagnosis

Interventions
11.5
34.5
11.1
255
Segmented neutrophils: 82%
Band forms: 1
Basophils: 0
Eosinophils: 1
lymphocytes: 16
Monocytes: 4
136
4.1
105
22
23
1.0
134
Color:
Pale yellow
Turbidity:
Clear
Specific Gravity:
1.020
pH:
5.0
Glucose:
Negative
Ketones:
Trace
Blood:
Negative
Protein:
Negative
Bilirubin:
Negative
Urobilinogen:
0.1-1.0
Nitrates:
Negative
Leukocyte Esterase:
Negative
Casts:
None
Red Blood Cells:
0-10
White Blood Cells:
0-10
Epithelial Cells:
2-10
Amylase: 45
Lipase: 12

UHCG: Positive
BHCG Quantitative: 1100 IU/mL
Other Labs
Cervical spine fracture
Spinous process
Body
Transverse process
Lamina
Cervical spine subluxation
Cervical spine strain
Herniated cervical disc


FINAL
DIAGNOSIS
? Epidural hematoma
:
Repeat serial Head CTs
Conservative management
Observation
Repeat imaging
q6 hours (or so)
Keep NPO
Reversal of anticoagulation
Stop coumadin
Vitamin K
FFP
Surgical evacuation if deteriorating
Not needed in this case...
Normal heart, no cardiomegaly, no infiltrates, pneumothorax, or free air.

Left anterior rib fractures of 7th and 8th ribs
Abnormal positioning of some of the facet joints due to distraction but no dislocation
Additional fracture of the body of C4
The vertical orientation of the fractures of the bodies of C4 and C5 indicate that there was severe axial loading.
(In fact these vertebral bodies kind of 'exploded' with propulsion of a bone fragment anteriorly (teardrop) and the larger part posteriorly against the spinal cord.)

Interventions:
Teardrop Fracture:
Spinal immobilization
Admission
NPO
Spinal surgery consultation
MRI
Analgesics
Closed reduction under fluoroscopy
Halo vest immobilization
Possible surgical immobilization
Flexion teardrop fracture of C5
EKG
Oriented to person, place time
Arrives via EMS, collared and boarded

HEENT
: EOMI, PERRLA, sclera non-icteric
Ecchymoses to midline, anterior forehead, No deformity to calvarium
Pharynx and nares are normal
No hemotympanum
Neck
: tender in midline posteriorly over C4-C6
Tender over bilateral trapezium muscles, no deformity. Range of Motion (?)
Chest
: No deformity, normal excursion, midline ecchymoses,
tender to midline sternum without crepitus
Lungs
: CTAB
CV
: regular rhythm, tachycardic, S1S2 without gallop, rub, or murmur, tender
to left anterior chest about 5th-9th ICS
Abdomen
: soft, tender diffusely, worse in RUQ and epigastric regions, no
ecchymoses or abrasions, normal BS
Rectal:
good tone, light brown, soft stool, trace heme +
Ext
: no deformities or tenderness or ecchymoses, Pulses 2+ throughout
bilaterally
Back
: nontender in midline and to paraspinous muscles
Neuro
: No facial asymmetry, CN 2-12 intact,
Motor and sensory intact throughout, non-focal exam
Your patient was not wearing her seat belt when her car struck a telephone pole 30 minutes ago. She states she had been driving all night and fell asleep at the wheel. She doesn't really remember the collision, and the first thing she can recall afterward is waking up with a sore neck while the paramedics were knocking on the window. She quickly regained consciousness and unlocked the door. The neck pain is described as sharp. She has no prior neck problems. She does complain of a diffuse headache and achiness in the center of her chest and abdomen, but she denies problems with her extremities.
Fracture of the body of C5 with a small fragment anteriorly
Fracture of the spinous processus of C4
Acute angulation at the level of C5C6 with displacement of C5 in posterior direction

Head
Intracranial hemorrhage
Epidural hematoma
Subdural hematoma
Subarachnoid hemorrhage
Cerebral contusion
Coup-contracoup
Scalp contusion/soft tissue
injury

Possible Epidural Hematoma
Non-smoker
Drinks alcohol socially
Denies any non-prescription drug use
Sexually active with husband only Monogamous for 4 years. No condom use
Job: Works at State Street

Family History
:
Father: Unknown
Mother: Unchanged

Social History
Vital Signs:
Temp: 37.0 C (98.6 F)
BP: 102/62 mmHg
HR: 110/min, irregular
RR: 20/min
O2 Sat: 97% on RA
Abdominal contusion
Liver laceration
Splenic laceration
Hollow viscous injury
Pancreatic contusion/rupture
Gastric rupture
GERD

Chest contusion
Rib fractures
MI
Atrial fibrillation
PTX
PE
Cardiac contusion
Pericarditis
Pulmonary contusion

FAST Exam
Reading: Soft tissue swelling to left frontal forehead. No fracture of skull. Faint hyperlucency to left frontal lobe may be suggestive of epidural/subdural hematoma. Clinical correlation suggested.
Abdomen/Pelvis
Liver Laceration
Rib Fractures
Rib Fractures:
Pain management
Incentive spirometer
To bind or not to bind?

Interventions:
Liver Laceration:
Grading of injury
Fluid resuscitation
Surgery consultation
If stable:
Conservative
If unstable:
Surgical
Analgesics

ABDOMEN:
1. Few fluid-filled loops of small bowel are present but are nonpecific.
2. Liver with 2.5cm laceration to lateral aspect.
3. Gall bladder present
4. Fat containing umbilical hernia.
5. No abdominal free air of intraperitoneal fluid
PELVIS:
1. No evidence of diverticulitis or acute inflammatory process in the pelvis.
No evidence if pelvic or retroperitoneal free air or fluid
Airway/Breaching
Unstable airway/unsecure airway
Patients with severe maxillofacial injuries
Patients requiring immediate airway intervention
Facial burns or burns with significant suspicion of inhalation injury
Moderate-severe respiratory distress; sub-Q emphysema of the face, neck or chest
Circulatory
Systolic BP < 90mmHg or HR > 120
Witnessed cardiac arrest from trauma
Arterial Bleeding
Spinal Shock (Hypotension & normal HR with neuro deficits)

CNS
GCS ≤ 8
Head injury with LOC > 5 min with one or more other physiologic derangements
Known spinal cord injury
Neurologic deficits with suspected spinal cord injury (any level)
Chest/Abd/Pelvis
Cardiac injury
Widened mediastinum
Diagnosed abdominal or pelvic injury with shock Major pelvic injury with shock
Major chest wall injury such as flail chest/sucking chest wound

Extremities
Multiple long bone fractures with shock
Amputation of proximal extremity (not digits)
Pulseless extremity with evidence of trauma
Mechanism of Injury
Penetrating trauma to the head, face, torso (chest, abd, buttocks, back)
Ejection or thrown from any vehicle with presence of other criteria for Level I activation
Fall from height > 10 feet are Level II unless meeting Level I criteria
High voltage electrical injury
Burns > 20% BSA or burns combined with any other injury
Massive crush injury
Trauma Criteria #1
Trauma Criteria #2
Trauma Criteria #3
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