Kas 15–1E : 42 year-old man injured by traffic accident
42 years old man injured by traffic accident as a front passenger.
Present illness : In the March 4, 2003, around 16:00 o´clock, a car crashed into a
lighting pole. Salvage and rescue servis arrived at 16:50 o´ clock, examinated the
patient, inserted venous cannula with application of Hartmann infusion and
Fentanylum 2 ml solution and transported the patient into the outpatient department
of Surgical Clinic of Faculty Hospital Královské Vinohrady.
At admission, the same day, 17: 20 : The patient is conscious, answering
adequately, remembers the circumstances of the trauma. Complaining of pains in the
right half of the thorax, has breathing difficulties, especially especially during cough.
Physical examination : regular HR, 88 min., BP115/80, acrocyanosis.
Head : percussion painless, eyeball in middle position, isocoria, symmetric reaction.
Neck : free mobility of cervical spinal column, painless when moving.
Chest : palpately painfull in the lower third of the middle axillar line on the right side,
palpately crepitation and fulmination. Painfull percussion and weakened auscultation
on the right side of the chest.
Abdomen : dif. tympany resonance, not painful, palpately soft.
Legs : free active and passive mobility, without trauma.
Questions :
1. What is the cause of crepitations and fulminations on the chest wall ?
2. What other examinations would you perform on the injured patient ?
3. What did you discover during the physical investigation in pneumothorax ?
4. Injured pneumotorax – classification?
5. What other injuries of the chest might be connected with traumatic pneumotorax ?
6. How do we procede during the therapy of traumatic pneumotorax at the traumaplace and
in hospital ?
PF : What is hypoxia, what kinds of hypoxia do you know and how could hypoxia
endanger the patient ?
PA : Pathological content of pleural cavity. Pneumothorax
Kas 15-2E : Car driver injured after a crash accident (hit a tram).
Present illness: March, 20, 2003, around 16:00: A man crashed his car into tram.
Ambulance arrived at 16:15. After freeing the man out of car, a resuscitation was
immediately commenced because of sings of respiratory insufficiency. Venous
cannula was inserted, infusion applied (Dextran), and, after applying barbiturate and
muscle relaxant intubation was performed. Artificial lung ventilation followed.
Physical finding: Acrocyanosis, HR 124 min, BP 80/50, paradoxial movements of
the left half of the chest during inspiration. Weakened respiration on the left side.
Oedema and pathological mobility in the middle of the left leg shank. The limb was
therefore fixed to the Kramer splint.
The casualty brought at 17:00 at the addmision ward. Feeling dull during the
examination, intubated and ventilated. Infusions applicated (Ringer, Haemacel).
Pathological crepitation and fulmination above the third and seventh rib in the front
and rear axillar line.
Questions:
1. What kind of injure is being described?
2. What other compensatory solutions are used in the early phase of trauma?
3. What examinations would you perform from the blood sample ?
4. What other examinations would you make?
5. How do we divide blunt chest trauma?
6. What intrathoratic injuries are connected with the multiple rib fractures?
7. What other therapeutic procedures do you know?
P.F. The mechanisms and phases of shock
PA: Anemia, pathogenesis and division.
Kas 15 – 3E : Injured front passenger
Injured front passenger from a traffic accident (car crashed directly into concrete
column)
Anamnesis: The emergency car came in 20 minutes after the accident to handle the
patient.
Patient’s complaints: Pain of the right hemithorax, the right side of the abdomen and
in the right coxal area. Patient’s blood pressure was 90/50, pulse 128/min. There
were signs of peripheral cyanosis. In the place of crash accident before
transportation to the hospital a cannula into a peripheral vein was inserted and
Ringer solution was administered. Barbiturates and myorelaxans were administered;
the patient was intubated and ventilated artificially. During transportation into the
hospital another solution was administered (Dextran 1000ml). On admission to the
Critical care department the patient is intubated, with peripheral vein cannulation and
under influence of drug suppressing consciousness.
Physical examination:
Blood pressure: 100/50, pulse 128/min.
Chest: based on auscultation breathing attenuation on the right side, palpable
crepitation in the area of lower right ribs in the middle axillary line.
Abdomen: normal palpable finding, without palpable resistance.
Per rectum examination: bulge Doulgas space.
Subcutaneous hematoma is present in the area of right lumbal and gluteal area.
Bone pelvis doesn’t show any instability. Other findings are normal.
Lab examination:
Blood count: Ht 25, ery 2 800 000, leuko 19 000, trombo 90 000.
Urine: negative chemical analysis.
Liver tests: bilirubin 18.6 um, ALT 2.5 ukat, AST 3.7 ukat.
Questions:
How would you evaluate injury of the patient?
How do you evaluate results of lab examination?
What is necessary to do by hypovolemic shock?
What next examinations do you recommend to perform after stabilization of the
patient?
What procedures are required by liver injury?
How is it possible to assess the diagnosis of hemoperitoneum?
Which organs could be damaged in pelvis injury?
Pathofysiology: What is cyanosis, in which types of hypoxia is/isn’t present and why?
Pathological anatomy: Pathological content of abdominal cavity.
Kas 15-4E : Injured after falling from a height.
Injured after falling from the height of 6 meters, hit the left side of chest and left
lumbal region.
Present illness: The casualty brought to the outpatient department about fifteen
minutes after the trauma. Conscious, complaining about pain in the left half of chest
and the left lumbal region.
Physical examination: BP 90/50, HR 124 min.
Chest: palpately pain and crepitation above the left lower ribs, rear axillar line. Lungs:
weakened respiration at the same area. Abdomen: below the level, free breathing,
palpately soft but painful in the area of left hypochondrium and mesogastrium. Painful
percussion in the left lumbal region. Hematoma in lower part of the chest.
Laboratory: Blood count hgb 98 g/l, htk 29%, ery 3,5, leu 14,
Urine: Massive hematuria.
X-ray: serial fracture of 7th-10th rib, pneumothorax and fluidothorax on the left,
contusion in the lower part of left lung.
CT: contusion in the lower part of left lung, partial collapse of lower lobe,
pneumothorax and free liquid in pleural cavity- hemothorax.
Free liquid in peritoneal cavity- hemoperitoneum.
Cleft in the spleen parenchyma (hilus).
Multiple clefts in left kindey parenchyma with perirenal liquid- hematoma.
PF: Crush syndroma and compartment syndrom
PA: Pathological content of pleural cavity. Pneumotorax.
Kas 15-5E : An 80-year old woman found in her apartment
An 80-year old woman was found in her apartment laying on the floor. She was not
able to stand up. She was brought to the emergency by emergency car.
Familiar history: Nothing important.
Personal history: in age of 50 gynecological operation (the lady is not remembering
the exact diagnosis), hypertension, non smoker. Before the accident she was able to
walk normally.
Social history: the lady is living alone; she was a teacher. She has one son – he
comes to her two times a week.
Patient’s recent problems:
This morning she fell down (she doesn’t know exactly), maybe she had vertigo.
During the fall she hit her head, after she waked up, she was not able to stand up on
her right lower extremity.
Present status:
Patient is oriented, forehead hematoma with percussion sensitivity, isochoric pupils,
symmetric eye movement. External acoustic meatus clear without signs of bleeding.
Neck: the finding is corresponding with the age of patient.
Chest: is stable, without pain, clear breathing, blood pressure 140/100, pulse 80/min.
Abdomen: normal palpable finding, without palpable resistance, liver normal size,
spleen not palpable, tapottement negative.
Upper extremities: without pathology
Lower extremities: 2cm shortening of the right leg, external rotation, movement not
possible because of pain, palpable sensitivity in the area of major trochanter and
below inguinal region. No failure in blood perfusion or in sensitivity of the leg
periphery.
Questions:
Which diagnosis is most probable?
Which examination should be the next?
Is necessary to think about another disease or other acute problem: Which one?
X-ray: showed fracture of right neck of femur, just bellow the caput of femur with
movement of distal fragment proximally
What is the correct diagnosis?
Which factors are important for next treatment? Which other examination would you
suggest?
Are there any life-threats? If yes, which one?
Pathofysiology: Immobilization syndrome.
Pathological anatomy: Osteoporosis and osteomalacia
Kas 15-6E : 35-year old man after fall from a height
35-year old man was transported to emergency by emergency car after he fell down
from a tree. The paraplegia of lower extremities was present in patient.
Familiar history: Nothing important.
Personal history: common diseases, no chronic medication, no allergies,
appendectomy in 1985
Social history: engineer, scientific worker. He lives together with his family.
Patient’s recent problems:
This morning around 9:30 the patient has been picking cherries. A branch of the tree
broke down while standing on it; he fell down from the height of 4 m on his buttocks.
Immediately after the accident he was not able to move his legs, there was lack of
sensitivity in the legs. His wife called the emergency. He was transported with help of
(vacuum) air-bed, unaccompanied by a doctor. After arrival to the place of accident,
Fentanyl (2 mL) was administered intravenously, infusion inserted. He complains of
neck pain in the Th/L area, impossibility of legs movement and their non-sensitivity.
Till now he didn’t urinate. He didn’t hit his head, no unconsciousness, no vomiting.
Present status:
The patient was examined in laying position. He was well oriented, cooperating,
without dyspnoea, without icterus and cyanosis.
Head and neck: the finding is corresponding with the age of the patient, without signs
of meningeal irritation.
Chest: stable, without pain, clear breathing, heart sounds clear, pulse regular 76/min,
blood pressure 140/80.
Abdomen: in niveau, normal palpable finding, without palpable resistance, painless,
liver normal size, spleen not palpable, tapottement negative, insensitiveness distally
from the navel.
Bone pelvis: doesn’t show any instability. Pressure is not painful.
Upper extremities: without pathology
Local status:
The patient is examined laying on his back and left hip. Edema, hematoma and
palpable pain are present in Th/L backbone area. Movement of backbone is not
possible to examine, insensitivity distally from navel. Active leg motion is not possible,
the passive one in all articulations of lower extremities without limitation.
Questions:
1. What is going on? Which diagnosis is most probable?
2. Could you suggest algorithm of following examinations?
Lab examination
Hgb 146 g/dl, Ery 3.6, Hct 0.42 %, Leu 5.6, Na 143 mm/l, K 4.2 mm/l, Cl 117 mm/l,
bili 12.9 umol/l, AST 0.30 ukat/l, ALT 0.42 ukat/l, urea 6.4, creatinine 75 umol/l,
Urine + sediment: negative
Neurological examination:
Transversal lesion of spinal cord in the level of L1.
3. Could you say now what is going on? Which examination would you suggest to
perform now?
X-ray examination:
Cominutive fracture of L1 vertebra, with 50% reduction of vertebra height and with
protrusion of back part of vertebra to vertebral canal, enlargement of inter-spinosal
distance L1/2.
CT examination is recommended.
CT examination:
Splintery fracture of vertebra body with protrusion of vertebra fragments into vertebral
canal, the canal is narrow down to 30% of its lumen and the dural sac is pressed.
Subluxation in L1/2.
Pathofysiology: Explain term peripheral and central paresis. Which type can be found
in this case?
Pathological anatomy: Injury of the head and brain.