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Trauma and Bleeding Chief Complaint: 31-year-old Afican American male injured whilerok-climbing History of Present Ilness: This 31-year-old male was rock-climbing with two friendsat a national park 14 miles away from the nearest hospital when he suddenly lost his footing and slid 18 feet to the ground. Both friends who witnessed the fall said that he slid against sharp rock all of the way down, landing almost in a standing-up position finally slumping to the ground. They also said that his head was not jarred during the slide. The man was alert and oriented when his friends reached him, and could move all four extremities quite easily. He had multiple scrapes over his anterior torso and a larg gash over his right anterior upper thigh (near the groin) which was bleeding profusely.A makeshift tourniquet slowed the bleeding. The party wa hospital. The became increasingly disoriented during the flight, reaching the emergency room s able to radio to the park rangers station for help. The ranger, in turn, contacted the med-evac unit at the city each arm in-flight, and normal saline fluid was administered intravenously. The patient helicopter located and evacuated the man. A large-bore IV was placed in about 40 minutes after the fall. Past Medical History: According to the mans friends, the patient was in good health prior to the accident, with no history of allergies, anemia, bleeding disorders, or diabetes mellitus. Family History: Family history was not attainable. The patients family lived in another state and could not be contacted. Physical Examination: The patient was lethargic but responsive to shouting and sternal pinch. He had multiple abrasions over his chin, neck, anterior thorax, and abdomen. A six-inch-long, half-inch deep laceration was noted in the right inguinal region, extending into the right, upper thigh. The tourniquet placed in this area was soaked with blood. Height 6 2, weight 205 lbs. Vital signs were as follows: HR 112 (supine) and 128 (sitting), BP 108/ 60 (supine) and 92 /52 (sitting), RR 32, rectal temp 99.4°F. Skin was cold and clammy, and nail beds, palms, and mucous membranes were pale. Carotid, radial, left femoral, and dorsalis pedis pulses were all weak and thready. Cranial nerves, to the extent that they could be tested, were intact bilaterally. Pupils were equal, regular, and reactive to light. External jugular venous collapse point was not visible in either the sitting or recumbent position. Heart sounds were regular, tachycardic, with no murmur, S3 or S4 sounds. Lungs were clear to percussion and auscultation. Abdominal guarding was noted, attributable to multiple lacerations; no masses were felt. Blood was drawn, typed, and crossed. A urethral catheter was placed to monitor urinary output, and another catheter was placed into the right subclavia n vein and threaded into the superior vena cava to monitor central venous pressure. A cardiovascular surgeon was consulted for repair of the lacerated right femoral artery.
Laboratory Studies: Laboratory studies of the venous blood revealed the following. Blood Type A+ (normal 4,000 to 11,000) Total whiteblood cell (WBC) count-7,400 WBCs mm white blood cell (WBC) counts 7,400 WBCs /mm3(normal = 4,000 to 11,0 normal . 55-70 %) (normal =42-54%) (normal 14-18 gm/dl) (normal 136-145 mEq/L) (normal 3.5-5.1 mEq/L (normal = 96-106 mEq /L)」 normal 6-23 mg /d (normal- 0.7-1.5 mg / di) (normal 70-160 mg / d (normal 0-33 IU/L) normal 041IU/L) Differential WBC count revealed 59% neutrophils Hematocrit-46% Hemoglobin-15.0 gm/d Sodium (Na)= 138 mEq / L Potassium (K) 5.1 mEq/L Chloride (C)- 104 mEq/L BUN - 27 mg/d Creatinine - 1.9 mg /di Glucose = 165 mg/dl SGPT 41 IU/L SGOT-48 IU / L Laboratory studies of the arterial blood revealed the following: (normal-7.35-7.45) Blood pH = 7.28 pCO2 31 mm Hg (normal 40 mm Hg) (normal-90-100 mm Pomogobin 9 ati% рог-78 mm Hg Hemoglobin-O2 saturation-88%(normal=94-100%) HCOs] 14 mEq/L (normal-22-26mEq /L) Urinary output in first 60 minutes in ER was 20 ml (color was dark yellow). Urine specific gravity 1.029 (normal 1.003-1.030). Central venous pressure ranged from 1 to 3 cm H20 throughout the cardiac cycle (normal range-5.5 to 13 cm H2O). ECG revealed normal sinus rhythm with slight ST-depression in most leads. As soon as whole blood became available, 2 units were rapidly transfused into this patient Questions 1. What is this patients primary problem? 2. List all of the evidence you can that supports your answer to #1. 3. Describe in detail how this patients body would compensate for his primary problem. 4. Is this patients urinary output normal? Why is it important to monitor this patients urinary output?
5. What is specifically causing each of the following findings? A. orthostatic hypotension B. elevated creatinine and BUN C. elevated SGOT and SGPT D disorientation and lethargy E. decreased central venous pressure. F. pale nail beds and mucous membranes G. ST-segment depression 6. How would you characterize this patients acid-base status? Give specific evidence for your answer 7. Poiseuilles equation describes the variables that determine arterial blood flow rate. How have the variables in Poiseuilles equation been altered from normal in this patient? 8. What is the hematocrit? If the hematocrit was in the normal range, why was the patient given 2 units of whole blood? 10. If this patient were stabilized, how would his hematocrit change over the next 24 hours? 11. Why was whole blood (rather than packed RBCs) given to this patient? 12. Physicians attending to this patient debated ordering an abdominal CT scan, but decided ultimately against it. Why might they have ordered one?
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Answer #1

1. The primary problem of the patient is hypovolemic shock as a result of severe hemorrhage due to the injury which he got during rock climbing .

2. The patient is a 31 year old African male who was rock climbing with his two friends in a national park , while climbing the patient suddenly lost his footing and slide 18 feet to the ground . The two friends who witnessed the accident said that he slid against sharp rock all the way down in a standing position and finally slumped on the ground .

3. The patient is in hypovolemic shock due to severe hemorrhage due to the deep cut of the femoral artery which had caused excessive blood loss and due to this patient is in shock . To compensate for this first of all bleeding has to be stopped by conducting the repair of femoral artery asa soon as possible or by other methods , multiple blood transfusions has to be done after doing cross matching and blood typing , IV fluids has to be administered for body fluid loss , patient has to be put in Trendelenburg position and continuous monitoring of the patients vitals has to be done to avoid complications and for early assessment of adverse event.

4. As the patient is in hypovolemic shock ,in hypovolemic shock one of the parameter which we assess to check the effects of IV fluid administration ,blood transfusion etc is urine output . Urine output should be 30 ml /hour ,it means patient has adequate input and output and is recovering from the shock .

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