# Clinical Cases: Trauma Emergencies

## Case 1: Multisystem Trauma with Hemorrhagic Shock

### Patient Demographics
- **Age:** 34 years
- **Sex:** Male
- **Occupation:** Delivery driver

### Mechanism of Injury
High-speed motor vehicle collision. Unrestrained driver, vehicle rollover with partial ejection. Estimated speed 55 mph. Prolonged extrication (25 minutes). GCS at scene: 10.

### Prehospital Care
- Cervical spine immobilization
- 2 large-bore IVs, 500mL NS initiated
- Oxygen via non-rebreather
- EMS blood pressure: 72/palp
- EMS heart rate: 138 bpm

### Trauma Team Activation

**Level 1 Trauma Activation Criteria Met:**
- GCS <14
- SBP <90
- Ejection from vehicle
- Prolonged extrication

### Primary Survey (ABCDE)

**Airway with C-Spine Protection:**
- Speaking incoherently
- Blood in oropharynx
- Cervical collar in place
- Airway at risk - prepare for RSI

**Breathing:**
- RR 28, labored
- Decreased breath sounds on LEFT
- Dullness to percussion on LEFT
- Trachea midline
- SpO2 88% on NRB

**Circulation:**
- HR 142, weak and thready
- BP 68/palp
- Capillary refill >4 seconds
- Cool, mottled extremities
- FAST positive - free fluid in Morrison's pouch
- Pelvis stable on single compression

**Disability:**
- GCS 9 (E2V3M4)
- Pupils: 4mm bilaterally, reactive
- Glucose: 118 mg/dL
- Moves all extremities to pain

**Exposure:**
- Open deformity right femur
- Large scalp laceration
- Multiple abrasions
- Core temp: 35.8C

### Immediate Life Threats Identified

1. **Left hemothorax** - decreasing breath sounds, dull to percussion
2. **Hemorrhagic shock (Class III-IV)** - hypotension, tachycardia, AMS
3. **Intra-abdominal hemorrhage** - positive FAST
4. **Open femur fracture** - ongoing blood loss

### Resuscitation

**Airway:**
- RSI performed with inline stabilization
- Etomidate 20mg + Succinylcholine 100mg
- 7.5 ETT placed, confirmed with ETCO2
- Post-intubation CXR: ETT 3cm above carina

**Breathing:**
- Left tube thoracostomy: 1200mL blood immediately drained
- Lung re-expanded
- SpO2 improved to 96%

**Circulation - Damage Control Resuscitation:**
- **Massive Transfusion Protocol activated**
- Blood products: 1:1:1 ratio (PRBC:FFP:Platelets)
- First cooler: 6 units PRBC, 6 units FFP, 1 pack platelets
- **Tranexamic Acid (TXA)** 1g IV bolus (within 3 hours of injury)
- Permissive hypotension target: SBP 80-90 mmHg
- **Minimize crystalloid** - only 1L NS total
- Calcium gluconate 1g for citrate toxicity prevention

**Hemorrhage Control:**
- Tourniquet applied to right thigh above femur fracture
- Pressure to scalp laceration

### Secondary Survey (Abbreviated - patient unstable)

**Head:** Large stellate laceration, no skull depression
**Face:** Periorbital ecchymosis bilateral
**Neck:** C-collar, no step-offs
**Chest:** Tube thoracostomy in place, equal breath sounds
**Abdomen:** Distended, tender, positive FAST
**Pelvis:** Stable
**Extremities:** Open right femur fracture, compartments soft
**Back (log roll):** No step-offs, no wounds

### Imaging

**Portable CXR:**
- ETT in good position
- Left chest tube in place
- Lung re-expanded
- Multiple left-sided rib fractures

**Pelvis XR:**
- No pelvic fracture

**FAST:**
- Positive: Free fluid in Morrison's pouch and pelvis
- No pericardial fluid

### Hemorrhagic Shock Classification

| Parameter | Patient | Class III |
|-----------|---------|-----------|
| Blood loss | Est. 1.5-2L | 1.5-2L |
| Heart rate | 142 | >120 |
| Blood pressure | 68/palp | Decreased |
| Mental status | Confused | Anxious/Confused |

### Operative Management

**Decision: Emergent laparotomy**
- Persistent hypotension despite MTP
- Positive FAST with abdominal distension
- Hemothorax output decreasing (not surgical threshold)

**OR Findings:**
- Grade IV liver laceration (controlled with packing)
- Grade III splenic laceration (splenectomy performed)
- 2L hemoperitoneum
- Damage control laparotomy - abdomen left open

**Orthopedic Surgery:**
- External fixation of right femur fracture
- Definitive fixation delayed until stable

### Post-Operative Course

**ICU Admission:**
- Continued MTP until INR <1.5, fibrinogen >150
- Weaned from vasopressors day 2
- Extubated day 3
- Abdominal closure day 4
- Femur ORIF day 5

**Total Blood Products (first 24 hours):**
- 18 units PRBC
- 16 units FFP
- 3 packs platelets
- 10 units cryoprecipitate

### Teaching Points

1. **Damage Control Resuscitation:** 1:1:1 ratio, permissive hypotension, minimize crystalloid
2. **TXA within 3 hours:** Reduces mortality in bleeding trauma
3. **Tube thoracostomy thresholds:** Initial >1500mL or ongoing >200mL/hr = OR
4. **FAST guides but doesn't replace clinical judgment:** Unstable + positive FAST = OR
5. **Damage control surgery:** Control hemorrhage, prevent lethal triad, definitive repair later
6. **Lethal Triad:** Hypothermia, acidosis, coagulopathy - prevent/correct aggressively

### Clinical Image
![Trauma CT Liver Laceration](case_01_image.jpg)

**Image Description:** Contrast-enhanced CT of the abdomen demonstrating a high-grade liver laceration with active extravasation and hemoperitoneum, consistent with traumatic hepatic injury.

**Attribution:** Image from Radiopaedia.org, Case courtesy of Dr. Andrew Dixon. Licensed under CC BY-NC-SA 3.0. Source: https://radiopaedia.org/cases/liver-laceration-trauma

---

## Case 2: Traumatic Brain Injury with Herniation

### Patient Demographics
- **Age:** 19 years
- **Sex:** Female
- **Occupation:** College student

### Mechanism of Injury
Pedestrian struck by vehicle at approximately 30 mph. Found unresponsive at scene. Witnessed loss of consciousness immediately after impact.

### Prehospital Report
- GCS 6 (E1V2M3) at scene
- Left pupil dilated and sluggish
- Intubated in field for airway protection
- BP 142/90, HR 58

### Primary Survey

**Airway:**
- Intubated, ETT secured at 22cm
- ETCO2 confirmed

**Breathing:**
- Bilateral breath sounds
- Ventilating well
- SpO2 99%

**Circulation:**
- BP 158/92, HR 52
- Peripheral pulses strong
- No external hemorrhage

**Disability:**
- GCS 5T (E1VTM3)
- **Left pupil: 6mm, fixed**
- **Right pupil: 3mm, reactive**
- Localizes to pain on right, withdraws on left
- **Cushing's triad present:** Hypertension, bradycardia, irregular respirations

**Exposure:**
- Scalp laceration left parietal region
- Left periorbital hematoma
- No other obvious injuries

### Clinical Diagnosis

**Severe Traumatic Brain Injury with Left Uncal Herniation**

**Evidence:**
- GCS 5T (severe TBI = GCS ≤8)
- Unilateral dilated fixed pupil (ipsilateral CN III compression)
- Contralateral motor posturing
- Cushing's triad

### Secondary Brain Injury Prevention

**Targets:**
- Avoid hypoxia: SpO2 >90%
- Avoid hypotension: SBP >90 (ideally >100)
- Avoid hyperthermia: Target normothermia
- Avoid hyperglycemia: Glucose <180

### Herniation Management (ICP Crisis)

**Immediate Interventions:**
1. Head of bed elevated 30 degrees
2. Head midline (ensure C-collar not too tight)
3. **Hypertonic saline 23.4%:** 30mL IV push (osmotic therapy)
4. Brief hyperventilation: Target ETCO2 30-35 mmHg (temporizing only)
5. Sedation optimized: Propofol infusion
6. Avoid hyperthermia

### Imaging

**CT Head (without contrast):**
- Large left epidural hematoma (5cm x 3cm x 8cm)
- "Lens-shaped" hyperdensity
- Associated skull fracture crossing middle meningeal artery
- 12mm midline shift to right
- Effacement of left lateral ventricle
- Early uncal herniation

**CT Cervical Spine:**
- No fracture or malalignment

### Neurosurgical Consultation

**Operative Indication:**
- EDH >30mL
- Significant midline shift
- Neurological deterioration
- Evidence of herniation

**Decision: Emergent craniotomy**

### Operative Course

**Left Craniotomy for EDH Evacuation:**
- Large organized epidural clot removed
- Bleeding vessel (middle meningeal artery) coagulated
- Brain appeared contused but pulsatile post-evacuation
- ICP monitor placed: Opening pressure 35 mmHg, post-op 12 mmHg
- Bone flap replaced

### Post-Operative Course

**Immediate Post-Op:**
- Left pupil now 4mm and reactive
- ICP maintained <20 mmHg
- CPP maintained >60 mmHg

**Day 2:**
- Sedation lightened
- Following commands bilaterally
- GCS improved to 10T

**Day 5:**
- Extubated successfully
- GCS 14 (E4V4M6)
- Left-sided weakness improving

**Discharge (Day 14):**
- GCS 15
- Mild left hemiparesis (improving)
- Transferred to rehabilitation facility

### Epidural Hematoma Key Points

| Feature | Epidural | Subdural |
|---------|----------|----------|
| Shape on CT | Lens/biconvex | Crescent |
| Source | Arterial (MMA) | Venous (bridging veins) |
| Classic history | Lucid interval | Progressive decline |
| Crosses sutures | No | Yes |
| Prognosis | Good if treated early | Variable |

### Teaching Points

1. **Epidural hematoma classic presentation:** LOC, lucid interval, deterioration
2. **Dilated pupil = ipsilateral to lesion:** CN III compression from uncal herniation
3. **Cushing's triad = late sign of herniation:** HTN, bradycardia, irregular respirations
4. **Hypertonic saline preferred over mannitol:** More predictable response, no diuretic effect
5. **Hyperventilation is temporizing only:** Causes vasoconstriction, can worsen ischemia
6. **EDH is surgical emergency:** Excellent prognosis with rapid evacuation

### Clinical Image
![Epidural Hematoma CT](case_02_image.jpg)

**Image Description:** Non-contrast CT head demonstrating a large left-sided epidural hematoma with characteristic lens-shaped (biconvex) appearance, significant midline shift, and mass effect.

**Attribution:** Image from Radiopaedia.org, Case courtesy of Dr. Frank Gaillard. Licensed under CC BY-NC-SA 3.0. Source: https://radiopaedia.org/cases/extradural-haematoma

---

## Case 3: Unstable Pelvic Fracture with Hemorrhage

### Patient Demographics
- **Age:** 45 years
- **Sex:** Male
- **Occupation:** Motorcyclist

### Mechanism of Injury
Motorcycle collision with SUV. Patient T-boned at intersection, thrown approximately 20 feet. Wearing helmet. Found supine, alert, complaining of severe pelvic pain.

### Primary Survey

**Airway:** Patent, speaking
**Breathing:** RR 24, clear bilaterally, SpO2 95% RA
**Circulation:**
- HR 128, BP 82/56
- Weak peripheral pulses
- Cool, clammy skin
- Scrotal hematoma noted
- **Pelvis unstable on gentle AP compression** (ONE EXAM ONLY)

**Disability:** GCS 15, moves all extremities
**Exposure:** Road rash, no open fractures, blood at urethral meatus

### Immediate Interventions

1. **Pelvic binder applied** (sheet/commercial device at level of greater trochanters)
2. Two large-bore IVs
3. **Massive Transfusion Protocol activated**
4. Foley catheter **DEFERRED** (blood at meatus - need retrograde urethrogram first)
5. FAST examination

### FAST Results
- Negative for free abdominal fluid
- No pericardial effusion

### Diagnostic Imaging

**Portable Pelvis X-ray:**
- Open book pelvic fracture
- Symphysis pubis diastasis >4cm
- Left SI joint disruption
- Type B (AP compression) pattern

**CT Pelvis with Contrast:**
- Bilateral superior and inferior pubic rami fractures
- Left SI joint disruption
- Active arterial extravasation from left internal iliac artery branch
- Large retroperitoneal hematoma

**Retrograde Urethrogram:**
- Complete posterior urethral injury
- No contrast entering bladder

### Hemorrhage Source in Pelvic Fractures

**Three sources:**
1. **Venous plexus** (most common) - responds to binder/packing
2. **Arterial** (internal iliac branches) - requires embolization
3. **Bone surfaces** - responds to stabilization

### Management Sequence

**1. Initial Stabilization:**
- Pelvic binder (already applied)
- MTP continued: 4 units PRBC, 4 units FFP, 1 pack platelets
- TXA 1g IV

**2. Persistent Hemodynamic Instability:**
- Despite binder and blood products
- BP 78/50 after 6 units PRBC

**3. Angiography and Embolization:**
- IR performed pelvic angiogram
- Left internal iliac artery branches actively bleeding
- Successful Gelfoam embolization
- BP improved to 102/68 post-procedure

**4. Urologic Management:**
- Suprapubic catheter placed (posterior urethral injury)
- Definitive repair delayed 3 months

**5. Orthopedic Management:**
- External fixation placed in OR
- Definitive ORIF at day 7

### Resuscitation Summary

| Time | BP | HR | Products |
|------|----|----|----------|
| 0 min | 82/56 | 128 | - |
| 30 min | 78/50 | 134 | 6 PRBC, 4 FFP |
| Post-embo | 102/68 | 98 | Total: 10 PRBC, 8 FFP, 2 plt |

### Young-Burgess Classification

**Type B (AP Compression):**
- "Open book" injury
- External rotation forces
- Symphysis diastasis
- SI joint involvement
- High association with hemorrhage

### Teaching Points

1. **Single pelvic exam only:** Repeated manipulation worsens bleeding
2. **Pelvic binder ASAP:** Reduces volume, promotes tamponade
3. **Blood at meatus = urethral injury:** No Foley until urethrogram
4. **Negative FAST doesn't exclude pelvic hemorrhage:** Retroperitoneal not seen
5. **Angioembolization for arterial bleeding:** When unstable despite binder
6. **Preperitoneal packing:** Alternative if angio not available

### Clinical Image
![Open Book Pelvic Fracture X-ray](case_03_image.jpg)

**Image Description:** AP pelvis radiograph demonstrating an open book pelvic fracture with widening of the pubic symphysis greater than 4cm and disruption of the left sacroiliac joint, consistent with AP compression injury.

**Attribution:** Image from Radiopaedia.org, Case courtesy of Dr. Roberto Schubert. Licensed under CC BY-NC-SA 3.0. Source: https://radiopaedia.org/cases/open-book-pelvic-fracture