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Patient identified as Wyatt, male, early 20s, found prone roadside after bicycle vs. auto collision. Bystanders report patient struck by vehicle at about 35mph, thrown several feet, helmet fell off during crash, but was located at scene. On arrival, patient alert and oriented ×2, GCS 12, c/o severe left leg and pelvic pain. Visible deformity of left femur with crepitus; abrasions noted to face and upper extremities.

Airway intact, respirations 24/min, O2 sat 93% RA. HR 129, BP 94/54, skin pale, cool, diaphoretic. Cap refill >3 seconds. Suspected pelvic instability on exam. Appears to be superficial head lacerations, pupils equal/reactive.

Care provided: C-spine precautions maintained, O2 via non-rebreather at 15L with improvement to 98%. IV access ×2 (18G bilateral AC), 1L NS bolus initiated. Splint applied to Left thigh; pelvic binder placed. Pain managed with 50mcg IV fentanyl per protocol.

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Trauma laboratory panel:

CBCD

CMP

Ionized Calcium

aPTT

PT/INR

HCG Qualitative

Type & Screen

Bleeding risk appears either controlled or minimal involvement. Apparent fracture of left femur -- if arterial involvement was active, it would have presented on-scene and would have been noted by first responders and patient would have decompensated rapidly. Therefore, patient is male with some injury and fracture, hemoglobin levels are likely depressed albeit not critical requiring immediate intervention. Hemoglobin estimated at 10.0 g/dL (RR = 13.5 – 17.5 g/dL) for some nominal blood loss due to traumatic injury.

CMP and ionized calcium should be assessed to identify metabolic, renal, and hepatic disfunction due to traumatic injury. While CT scans should be immediately performed, damage to the kidney and liver should be assessed via blood work. The patient will likely require prophylactic antimicrobial therapy to mitigate infection risk due to the injury and if the renal clearance is compromised, varying antimicrobial agents can be excluded or those that would be hepatotoxic. Patient appeared alert and oriented, listed as "confused" no apparent metabolic acidosis, would expect an unremarkable K, CO2, Na, Anion Gap, Chloride level. Ionized calcium is often performed via ISE to rule-in or exclude cardiac involvement in traumatic patients, this level again should be unremarkable. (1.12 – 1.32 mmol/L)

Coagulation studies are customary in traumatic laboratory panels. aPTT and PT/INR would assess any inherent bleeding disorders that may be present prior to the injury and also would assess and evaluate the physiological response to trauma and the platelet functionality in the event of bleeding presentation. Injuries appear stable, bleeding appears due to immediate injury and not continued blood loss, would anticipate the aPTT and PT/INR to be within normal limits to possible upper limits of normal, excluding and pre-existing conditions. The patient is early 20s and not likely indicated for anticoagulation therapy, such as warfarin and should exhibit normal ranged values.

aPTT (Activated Partial Thromboplastin Time)

Normal range:

25 – 35 seconds

INR (International Normalized Ratio)

Normal INR (not on anticoagulation):

0.8 – 1.2

HCG Qualitative should be promptly performed on all unidentified patients to assess the necessity of OB intervention. However, the patient is male, and would not be indicated. Generally, the laboratory would be unaware of this if the patient presents as unidentified and will perform the HCG automatically per protocol.

Type & Screen in the event of blood loss, due to the presentation a Type & Screen would be performed per trauma protocol. However, the patient is young, male, and is a candidate for un-crossed blood Type O- if considered imminent. In the event of Type O- shortage, pathology and trauma attending approval, Type O+ would be acceptable in a male patient, if indicated. Assuming the patient is an American Caucasian male, the blood type may likely be O+ in which he would be candidate for either blood type if medically indicated.

UDS the patient is interesting considering they were the victim. The patient is identified, A&O, if unresponsive, parents, family, or a spouse/girlfriend, etc. could be contacted. Patient should be able to provide an active medication list, it mentions labored breathing but on 94% O2 room air saturation, the attending would monitor this and would provide supplemental oxygen if needed. If this continued to desaturate, BIPAP or intubation post sedation. Airway appeared intact per medical notes. In conclusion, after the patient was immediately stabilized, a UDS could be assessed if indicated but this only detects illicit medications or drugs, such as THC, methadone, fentanyl (state regulations often require this as part of a UDS now), cocaine, barbiturates, etc. This would require a urine sample, patient may be unable to provide this due to injury and associated pain and may require a urinary Cath to provide the sample. This may not be pertinent in the immediate trauma intervention. CMP would assess renal involvement. UA with C/S would identify blood loss or renal damage if present. Again, these are once the patient is stabilized.

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primary and secondary survey with meds/some info

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It was very useful to review the input from the other disciplines. Based on the information provided, I would draw a VBG, ABG, i-STAT troponin, BNP, CMP, CBC, PT/INR, aPTT, and a type and screen. These laboratory studies provide a fuller clinical picture of the patient’s physiological status. Blood gases confirm that the patient is oxygenating and ventilating appropriately. Coagulation values, blood counts, and blood typing are crucial to monitor and intervene quickly should hemorrhage take place.

The lab results reveal acidosis, possible infection, low hemoglobin, and a low hematocrit. Based on the lab results, my first priority as a nurse would be to ensure a patent airway and optimize oxygen delivery in an effort to stabilize the patient's gas exchange. This may include high-flow oxygen, assisted ventilation, or preparation for advanced airway support, depending on the severity of acidosis or respiratory compromise.

I would order a lactic acid level in light of the evidence of possible infection; utilize strict asepsis for all wound care; expect orders for blood, urine, and wound cultures; and begin broad-spectrum antibiotics as soon as cultures have been obtained. The early detection and treatment of infection are critical in trauma patients to avert sepsis and deterioration.

Given that the patient has a low hemoglobin and hematocrit, it is of the utmost importance that two large-bore IV sites are patent, the type and screen updated, and that the patient is closely monitored for signs of worsening hemorrhage or shock. At the first sign of tachycardia, hypotension, diaphoresis, change in mental status, or oliguria, reassessment and escalation of care should be immediately undertaken. Depending on the hemodynamic stability of the patient, preparation for blood transfusion or activation of a massive transfusion protocol may be indicated.

Trauma resuscitation literature places much emphasis on the early identification and treatment of hemorrhage and inadequate oxygen delivery. Among the information that takes precedence in this article includes, "the polytrauma victim with significant hemorrhage suffers a life-threatening acute reduction in oxygen delivery (DO₂) to tissue" (Haslam & Taylor, 2021, p. 2). This calls for a prompt stabilization, blood product administration where indicated, and ongoing reassessment with the aim of preventing further deterioration.

Reference (APA 7th Edition) Haslam, J. A., & Taylor, D. M. (2021). Physiological classification of hemorrhagic shock: A practical approach for trauma care. Journal of Clinical Medicine, 10(20), 4793. https://doi.org/10.3390/jcm10204793

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The Pathophysiology and Management of Hemorrhagic Shock in the Polytrauma Patient

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The recognition and management of life-threatening hemorrhage in the polytrauma patient poses several challenges to prehospital rescue personnel and hospital providers. First, identification of acute blood loss and the magnitude of lost volume after torso injury may not be readily apparent in the field. Because of the expression of highly effective physiological mechanisms that compensate for a sudden decrease in circulatory volume, a polytrauma patient with a significant blood loss may appear normal during examination by first responders. Consequently, for every polytrauma victim with a significant mechanism of injury we assume substantial blood loss has occurred and life-threatening hemorrhage is progressing until we can prove the contrary. Second, a decision to begin damage control resuscitation (DCR), a costly, highly complex, and potentially dangerous intervention must often be reached with little time and without sufficient clinical information about the intended recipient. Whether to begin DCR in the prehospital phase remains controversial. Furthermore, DCR executed imperfectly has the potential to worsen serious derangements including acidosis, coagulopathy, and profound homeostatic imbalances that DCR is designed to correct. Additionally, transfusion of large amounts of homologous blood during DCR potentially disrupts immune and inflammatory systems, which may induce severe systemic autoinflammatory disease in the aftermath of DCR. Third, controversy remains over the composition of components that are transfused during DCR. For practical reasons, unmatched liquid plasma or freeze-dried plasma is transfused now more commonly than ABO-matched fresh frozen plasma. Low-titer type O whole blood may prove safer than red cell components, although maintaining an inventory of whole blood for possible massive transfusion during DCR creates significant challenges for blood banks. Lastly, as the primary principle of management of life-threatening hemorrhage is surgical or angiographic control of bleeding, DCR must not eclipse these definitive interventions.

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This is the final and updated trauma sheet

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This is updated with the C-Collar