Janie, a 53 y.o. w/f, admitted c c/o SOB. VS -- BP - 128/92, T - 98.2, P – 102, R – 32 and labored. Skin cool and cyanotic.

Dx: pneumonia. Orders: O2 per n/c at 4 L/min IV of D5W at 125ml/hour NPO CBC BR c BRP Trauma Scenarios

Car Accident

1. Driver

Head-on 30mph impact, not restrained, airbag deployed. Steering wheel bent.

A: Clear B: Rapid, weak, shallow, BS clear C: Rapid, weak radial pulse; 3 second cap refill; no visible bleeds D: Response V, anxious, confused, PEARL E: No findings; patient cold and shivering

Cause: internal bleeding, shock, chest trauma

Changes: circulatory shutdown, u/c unless O2 given quickly

2. Front passenger

Side-on impact on his side, restrained, no airbag. Legs trapped under dashboard.

A: Clear B: Rapid, normal, BS clear C: Rapid, normal radial pulse, cap refill OK. Serious venous bleeding from left leg. D: Response A, anxious, in considerable pain. E: Open fracture of left tib/fib, deformations around kneecaps.

Cause: fractures to lower limbs, emotional shock

Changes: pain increases, shock develops unless bleeding stops

3. Rear passenger

Head-on 40 mph impact, not restrained. Went through windscreen, lying face-down on car hood.

A: Noisy, blood and teeth B: Slow, deep, BS clear C: Pale face, warm dry arm skin, no external bleeds D: Response U E: No muscle tone from abdomen downwards

Cause: low C-spine fracture from contra-coup against windscrren Changes: if moved, respirations stop; if airway not cleared, resp and circulatory arrest

Fight

4. Fists

Picked fight with rugby player in drunken stupidity. Got beaten around head and lost.

A: Clear, a few teeth gone, bleeding nose B: Rapid, normal depth, BS clear C: Rapid strong pulse, slowing D: A but sometimes talks nonsense, dizzy E: Strong smell of alcohol, bruising all around head

Cause: alcohol, concussion and a subdural haematoma

Changes: lowering LOC, goes u/c immaterial of treatment, postures and pupils go wide

5. Knife

Argument about possession of a boyfriend. Opponent wielded kitchen knife and plunged into left upper chest. Knife still in there.

A: Clear B: Rapid, shallow, frothy blood on lips. Left lung very noisy. C: Pulse 100+, weak, cap refil 3s, sweaty pale skin D: Numbness in left side below waist E: No other wound visible, casualty cold and shivering

Cause: Knife penetrated lung and damaged spinal cord

Changes: Tension pneumo / haemothorax in left lung develops

6. Gun

Argument at a hunt meeting; shotgun (small shot) discharged accidentally at range of 5m into abdomen and legs of saboteur

A: Clear B: Hyperventilating, breath sounds clear C: Pulse 120+, normal. Cap refil 2 seconds D: Can't move due to pain in abdomen and legs. E: Lots of small wounds with shot all over abdomen and upper legs. Substantial capillary blood loss. Cause: Obvious

Changes: None, no threatening injuries

Industrial Accident

7. Lift shaft

Lift power accidentally restored while workman in shaft. Both legs trapped between car and wall; been there 15 minutes.

A: Clear B: Rapid, normal, BS normal C: Rapid normal pulse, no external bleeding, CR normal D: Response A, in severe pain, legs deformed E: No circulation or motor control past pelvis

Cause: Multiple bilateral fracture, pressure on blood vessels

Changes: Rapid collapse if released (crush syndrome)

8. Explosion

Oxy-acetylene cylinder detonated in lab. Worker blown halfway across lab and burned.

A: Noisy, burns around face and mouth B: Rapid, wheezing, BS noisy left, silent right C: Rapid normal pulse, no external bleeding, CR hard to get due to burns D: Response P E: Partial thickness burns on head, front torso and front of arms

Cause: Airway burns, surface burns, right lung blown out from blast

Changes: Pulse speeds up and weakens as shock sets in, breathing speeds up and becomes shallower as airway swells

9. Fall

Worker falls through roof 30 foot to concrete floor, landing on back.

A: Clear B: Very rapid (40+) and shallow, BS noisy C: Pulse 110 and weak, skin cold and clammy, CR 3s D: Response V, unable to move below arms, PEARL E: Pelvis clearly misshapen

Cause: "Paper bag" lungs, pelvic fracture

Changes: will resp arrest unless breathing assisted and O2 given

Sports

10. Ski-ing

Lost control of direction and hit a tree at bottom of trail. Was travelling very quickly.

A: Noisy, blood and teeth B: Resp rate 38 shallow, breathing painful, BS clear C: Weak radial pulse of 120 D: Response P E: Deformed right knee, helmet damage

Cause: Flail chest

Changes: Pulse slows and stops unless respiration assisted

11. American Football

Linebacker blocked hard, does not get up again. Wearing helmet with faceguard.

A: Snoring respiration B: Rapid, laboured breathing C: Strong, rapid radial pulse D: Response U E: No obvious trauma

Cause: Concussion causing u/c and partial blocked airway

Changes: Stops breathing unless airway cleared.

12. Netball

Patient was knocked u/c by banging head on back wall while reaching for a shot. Recovered after a minute u/c

A: Clear B: Normal, clear BS C: Normal D: Response A, PEARL E: Pulse 90, resp rate 16, BP 120/70

Cause: Concussion

Changes: None, but remember possibility of slow haemorrage in brain