Author: Victoria Siddons / Editor: Steve Corry-Bass / Codes:NeuP8, SLO1 / Published: 20/02/2020
You are working in resus. It’s 4am and the pre-alert phone rings.
They are bringing in an intoxicated 45-year-old man who had been running down the pavement when he tripped and fell forwards, hitting his head on a lamppost. There was a Loss of Consciousness for about 2 mins. He has a GCS 13/15 (E3 V4 M6) with a very large wound on his right forehead.
His pre-hospital observations are: SpO2 96% on air HR 87 BP 96/61 RR 28 T 35.1oC
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Question 1 of 5
1. Question
On primary survey:
A- Patent & self-maintained.
B- Trachea central, equal chest expansion, good air entry bilaterally. SpO2 96% on air, RR 22.
C- Good bilateral radial pulses, no active bleeding, no obvious long bone deformity/injury, but there is a bruise to the right hip & ASIS with an overlying abrasion. There are no cannulas in situ. BP 79/52, HR 67.
E- Large vertical wound to forehead with active bleeding. T 35.2ËšC, BM4.6. The pt is in wet cold clothes.
A cannula is inserted and bloods are taken whilst the primary survey is being done.
What are the possible causes of hypotension at this time? Select all that may apply.
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Question 2 of 5
2. Question
The guidance from NHS England is that trauma patients should ideally have a CT scan within 30 mins (max 60 mins).
The patient remains with similar observations throughout assessment. There is no external bleeding seen.
The VBG shows Hb 129.
What steps do you want to take before going to CT? Select all that may apply.
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Question 3 of 5
3. Question
You transfer the patient onto the CT scanner and whilst the radiographers are doing their checks the blood pressure cycles and reads 60/41.
Which action is most appropriate?
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Question 4 of 5
4. Question
You give 1 unit of red cells and the next BP is 80/61. You proceed with the CT scan and take the patient back to resus to await the report.
The obs on arrival back to resus are:
SpO2 98% on air
HR 81
BP 85/61
RR 15
T 33.6ËšC
You repeat the VBG and the Hb is 142.
The hot report for the CT shows no significant or active bleeding.
Your team starts on the secondary survey and on examination of the limbs it is revealed that he can move and feel his arms as normal with power 5/5, but he cannot move or feel his legs with power 0/5. There is no response to plantar reflex. His sensory level is T6.
What is the most likely cause of hypotension now?
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Question 5 of 5
5. Question
The CT scan shows fractures to the occipital condyle, C4+5 transverse processes. It also shows a grossly distended bladder. There are no haematomas or signs of active bleeding.
You are now convinced that there is a neurogenic shock. You refer to the neurosurgical team who will come and see the patient.
If his blood pressure remains low, what are the best treatment options now? Select all that apply.
Cervical spine injuries are rare but potentially devastating. Immobilisation of the cervical spine on the slightest suspicion of injury is recommended by most resuscitation courses.
11 Comments
Further exposure to trauma needed to establish how to conduct primary and secondary surveys. Attendance of a trauma course would be useful.
Good case study.
Good learning point
Good case
Good case, informative
Nice one
good case to check knowledge
Excellent revision.
Good case
good trauma case
Interesting case in trauma emergency