Question

Mr. K., a 34-year-old male, was involved in a mountain bike crash. He was wearing a helmet, but he was traveling at a high speed down the mountain when he hit a rock and was sent over his handlebars and slammed against a tree. Initially he was conscious and complaining of abdominal pain and intense left shoulder and arm pain. He was bleeding from multiple abrasions and lacerations on his face, arms, and legs. His friend who was biking with him called 911.

It took approximately 30 minutes before emergency personnel reached him on the mountain bike trail. Initial assessment at the scene found him arousable and oriented but unable to maintain consciousness without stimulation; a suspected left shoulder dislocation with poor pulses on distal digits on his left arm; ecchymosis on the left abdominal wall; and bleeding from abrasions and lacerations on his face, arms, and legs. Initial vital signs at the scene were temperature 36.6° C, blood pressure 82/40 mm Hg, heart rate and rhythm 146 beats per minute with sinus tachycardia, and respiratory rate 36 breaths per minute and shallow. The prehospital team was able to intubate him and provided 100% FiO2to maintain an oxygen saturation greater than 95% by pulse oximetry. An intraosseous catheter was placed in his left leg, and intravenous fluid resuscitation was initiated with lactated Ringer’s solution. An indwelling urinary catheter was also inserted to monitor urine output. Four liters of fluid were administered before arrival in the emergency department. Mr. K. did not have a significant medical history, and his friend was not aware of any drug allergies.

Initial vital signs in the emergency department were temperature 36.2° C, blood pressure 96/68 mm Hg, heart rate and rhythm 136 beats per minute with sinus tachycardia, respiratory rate 16 breaths per minute on a transport mechanical ventilator with oxygen saturation 97%, and urine output approximately 50 mL and concentrated. He is minimally responsive to verbal commands, he is oriented to name, and his pupils are 2 mm in size and reactive to light. He has a 6-cm scalp laceration and a dislocated left shoulder with a compound fracture of the humerus. Neurovascular assessment of his left hand reveals decreased pulses and is cool to the touch. Chest radiograph reveals four broken ribs on the left side. Initial laboratory results were hemoglobin 6.9 g/dL, white blood count 18,000/μL, platelet count 100,000/μL, potassium 5.5 mEq/L; other electrolyte levels were unremarkable. Arterial blood gas results were pH, 7.19; partial pressure of arterial oxygen (PaO2), 160 mm Hg; partial pressure of arterial carbon dioxide (PaCO2), 36 mm Hg; bicarbonate (HCO3−), 18 mEq/L; base deficit, −14; and lactate, 9 mEq/L. Aggressive fluid resuscitation continues. A focused assessment with sonography for trauma (FAST) is performed to evaluate for internal abdominal bleeding. The prehospital team was able to contact his wife, and his friend remains in the waiting room of the emergency department.

Questions

1. What are the possible injuries based on the mechanism of injury?
2. What are the priority nursing interventions at this time based on his vital signs?
3. What is your interpretation of the laboratory results? What interventions do you anticipate based on

these results?
4. What are possible reasons for his unresponsiveness?
5. What additional studies or interventions do you anticipate the patient will need after the FAST? 6. What are potential complications based on his mechanism of injury and initial treatment?
7. What are the needs of the friend/family?

Answer 1

1.As he hit a rock ,sent over the handlebars and slammed against a tree the kinetic energy produced will be high which lead to blunt trauma to the abdomen or groin,dislocated left shoulder(may be his left arm landed during impact) and suspected organ injuries due to abdominal trauma .He was wearing a helmet but as he was travelling down at high speed he may have sustained a concussion in head.

2.Prepare for intubation and connect him to assisted mode ventilation,assess his neurological status , provide him sedation as prescribed by physician , ABO blood grouping plan to transfuse him platelets and RBC'S , Provide him intravenous fluids , close continous monitoring of vital signs.

3.He has exhibited more blood loss and fluid loss(dehydration) .So he need to be hydrated and blood components should be transfused.He is having respiratory acidosis.

4.Severe pain, loss of blood and possible concussion in head along with blunt injury to lungs and pericardial effusion.

5.CAT CT chest and MRI brain

6.Fluid overload or dilution of blood .

7.Psychological support