Patient details
- Name
- Mr O.R.
- Age / sex
- 24-year-old man
- Arrived
- Resuscitation room, 15:40
- Time of injury
- 15:05
- Brought by
- Ambulance crew
- Trauma team
- Called before arrival
- Record written
- During resuscitation, by the scribe
- Source
- Ambulance crew and patient
Handover from the ambulance crew
Mechanism: motorcycle rider struck on the left side by a car at about 60 km/h. Thrown three metres and landed on his left side. Helmet worn and undamaged.
Injuries found: pain in the left lower chest and left upper abdomen. Grazes on the left flank.
Signs at the scene: pulse 112, blood pressure 104/70, respiratory rate 24, oxygen saturation 95% on air, fully conscious.
Treatment given: cervical collar and spinal board, oxygen, one intravenous cannula, 500 mL of crystalloid.
Primary survey
Airway with cervical spine control, 15:41
Speaking in full sentences. No blood or vomit in the mouth. No injury to the face or neck. Collar and head blocks left in place.
Breathing, 15:42
Respiratory rate 24. Oxygen saturation 96% on high-flow oxygen. Trachea central. Chest moves equally on both sides, limited on the left by pain. Bruising and tenderness over the left ninth to eleventh ribs, with a grating feel. No segment moving inwards on inspiration. No air under the skin. Percussion note resonant on both sides. Breath sounds present and equal.
Action: oxygen continued. Chest X-ray requested.
Circulation with control of bleeding, 15:44
No external bleeding. Abdomen tender with guarding in the left upper quadrant. Pelvis: no deformity and no tenderness; not rocked. Thighs: no swelling or deformity.
Action: two large cannulae placed. Blood taken for full blood count, clotting, lactate and crossmatch of four units. Warmed fluid started, blood requested urgently, tranexamic acid given, all as directed by the team leader.
Bedside ultrasound, 15:48: free fluid between the spleen and left kidney and in the pelvis. No fluid around the heart. Both lungs sliding normally.
Disability, 15:50
Glasgow Coma Scale 15: eyes 4, verbal 5, motor 6. Pupils equal, 3 mm, reacting. Moves all four limbs. Capillary glucose 108 mg/dL.
Exposure, 15:52
Clothes removed. Log-rolled by four people: grazes and bruising on the left flank, no tenderness or step along the spine. No bruising of the perineum and no blood at the urethral opening. Temperature 36.1 °C. Covered with warm blankets.
Response to treatment
16:00 after the first unit of fluid: pulse 108, blood pressure 106/68.
16:10 pulse 122, blood pressure 94/58.
Other measures during the primary survey
ECG and oxygen monitoring attached. Urinary catheter passed after checking the urethral opening: 20 mL of clear urine. Chest X-ray: fractures of the left ninth to eleventh ribs, no air or blood in the chest. Pelvic X-ray: normal.
History, taken when the primary survey was complete
Allergies: none known.
Medicines: none. No anticoagulants.
Past illness and operations: none.
Last meal: lunch at 12:30.
Events: remembers the collision and the impact. Did not lose consciousness. Has pain in the left chest, the left upper abdomen and the tip of the left shoulder.
Secondary survey, 16:05
Head and face: no wounds, no bruising around the eyes or behind the ears, no fluid from the nose or ears.
Neck: no tenderness in the midline, trachea central, neck veins not distended. Collar kept on.
Chest: as above.
Abdomen: slightly distended. Grazes over the left flank. Tenderness and guarding in the left upper quadrant. No rigidity elsewhere. Bowel sounds present.
Pelvis and perineum: as above.
Limbs: graze over the left knee. No deformity. All pulses present. Sensation and power normal in all four limbs.
Back: as found on log-roll.
Summary
Working diagnosis
Haemorrhagic shock from bleeding within the abdomen, most likely a ruptured spleen, with left lower rib fractures.
Plan
- Team leader and senior surgeon at the bedside; theatre and anaesthetist informed.
- Blood products continued as directed. Keep him warm.
- Emergency laparotomy. He is not stable enough to go for a CT scan.
- Analgesia. Tetanus cover. Family informed by the senior doctor.
Where is the blood, and what else causes shock after blunt trauma
In a shocked trauma patient the cause is bleeding until proved otherwise. Name the five places blood is lost, then the causes of shock that are not bleeding.
| Cause | Clue from the mechanism or history | What you find | In this patient |
|---|---|---|---|
| Bleeding | |||
| External | Blood at the scene, scalp wounds, open fractures | Visible bleeding, soaked dressings | None seen |
| Chest | Blow to the chest, rib fractures | Dull percussion note, reduced breath sounds, blood on chest X-ray | Chest X-ray clear of blood |
| Abdomen | Blow to the flank or lower ribs, seat belt or handlebar injury | Tenderness, guarding, distension, free fluid on ultrasound | Most likely |
| Pelvis and behind the peritoneum | High-energy impact, fall from a height, crushed pelvis | Unstable or tender pelvis, bruising of the perineum, fracture on X-ray | Pelvic X-ray normal |
| Thighs | Fracture of the femur | Swollen, deformed, shortened thigh | Thighs normal |
| Shock that is not bleeding | |||
| Lung collapsed under pressure | Chest injury, sudden worsening | Trachea pushed away, no breath sounds and a drum-like note on one side, distended neck veins | Breath sounds equal |
| Blood around the heart | Blow to the front of the chest | Distended neck veins, quiet heart sounds, low blood pressure; fluid on ultrasound | No fluid around the heart |
| Spinal cord injury | Neck or back injury, weakness | Low blood pressure with a slow pulse and warm skin | Pulse fast, skin cold, limbs normal |
| Bruised heart | Blow to the sternum | Irregular rhythm on the monitor | Regular rhythm |
| Organs injured in blunt abdominal trauma | |||
| Spleen | Blow to the left side, left lower rib fractures | Left upper quadrant tenderness, left shoulder tip pain | Fits all the findings |
| Liver | Blow to the right side, right lower rib fractures | Right upper quadrant tenderness | Right side not tender |
| Kidney | Blow to the loin | Flank bruising, blood in the urine | Urine clear |
| Bowel and its blood supply | Seat belt injury | Bruise across the abdomen; peritonitis developing over hours | Rider, not a car passenger |
| Pancreas and duodenum | Handlebar or steering wheel into the upper abdomen | Few early signs; back pain | Cannot be excluded clinically |
| Bladder | Full bladder at impact, pelvic fracture | Lower abdominal pain, blood in the urine, cannot pass urine | Urine clear, pelvis intact |
Clinical signs related to this case
The signs you should look for in any patient with blunt trauma to the abdomen. For each one, know how to elicit it and what a positive result means.
| Sign | How to elicit it, or what you see | What it means |
|---|---|---|
| Signs of bleeding | ||
| Fast pulse, cold pale skin, slow capillary refill | The earliest signs, before the blood pressure falls | Blood loss. The pressure falls only after about a third of the blood volume is lost. |
| Low urine output | Catheter and hourly measurement | The organs are not being supplied |
| Left shoulder tip pain (Kehr's sign) | Pain at the tip of the left shoulder, worse lying flat | Blood under the left diaphragm: ruptured spleen |
| Abdominal distension with tenderness | Compare repeated examinations | Blood or bowel contents in the abdomen. A soft abdomen does not exclude it. |
| Marks on the skin | ||
| Seat-belt mark | Bruise across the lower abdomen or chest | Injury to bowel, its blood supply or the lumbar spine in a large share of these patients |
| Handlebar or steering wheel mark | Round bruise on the upper abdomen | Pancreas, duodenum or liver injury |
| Flank bruising and bruising around the umbilicus | Appears after hours to days | Bleeding behind the peritoneum |
| Lower rib fractures | Tenderness and grating over ribs nine to twelve | Left: spleen. Right: liver. Either side at the back: kidney. |
| Signs in the pelvis and perineum | ||
| Blood at the urethral opening, bruised perineum or scrotum | Look before passing a catheter | Urethral injury: do not pass a catheter; call the senior |
| Tender or deformed pelvis | Inspect; one gentle compression at most | Pelvic fracture: apply a pelvic binder |
| Signs in the chest that must not be missed | ||
| Trachea pushed to one side, no breath sounds, drum-like note | With distended neck veins and shock | Lung collapsed under pressure: treat at once without waiting for an X-ray |
| Low blood pressure, distended neck veins, quiet heart sounds (Beck's triad) | In a patient with a chest injury | Blood around the heart |
| Segment of chest moving inwards on inspiration | Watch the chest wall from the foot of the bed | Flail chest with bruised lung beneath |
| Signs in the head | ||
| Bruising behind the ear or around both eyes, clear fluid from nose or ear | Look during the secondary survey | Fracture of the base of the skull: no tube through the nose |
Teaching case. The patient is fictional and written to illustrate format and reasoning. Trauma care follows the team leader and local protocols.