Case Presentation

By: Dr. Aizaz Khalid(House Officer)

Dr. Tabeer Malik( Post-graduate Resident Y1)
Surgical Unit-II
Services Institute of Medical Sciences, Services Hospital
Lahore
 Pt Tariq 50Y, Male
 Smoker, no other known comorbidities
 Father of 2 sons
 Labourer by Profession
 SR : Dr. Qaim Deen
 Registrar: Dr. Saim
 Batch Incharge : Dr. Raees
 Bed PGR: Dr. Mohsin, Dr. Nouman
 Bed HO: Dr. Aizaz Khalid
 A direct collision with a speeding motorbike, resulting
in primary trauma
 Secondary trauma due to impact on the road
 Time : 1100 hours on 14/9/19
 Place of impact : Sialkot City
 Initial Hospital: DHQ Sialkot
 Suturing of wounds with Silk 1
 Fluid Resuscitation
 Pelvic Xray, which showed pelvic fracture
 Application of conventional Pelvic Binder.
 Patient referred to Services Hospital Lahore.
 Arriving Vitals:
 BP = 90/70 mm Hg
 HR = 110 bpm
 SaO2 = 94 @ R/A
 RR = 20 Bpm
 Temperature = 98.5
 GCS = M6V5E4
 Pupils Bilaterally Reactive to light.
 No evidence of ENT bleeding.

 Pelvic X ray showed Fracture of superior and inferior ramus

of Left Pubic Bone, and inferior ramus of the right pubic
bone, patient shifted to Trauma Bed.
 ATLS protocol initiated.
1. 5x2 cm laceration on lateral aspect of right eyebrow,
stitched with silk.
2. 5x1 cm laceration of right maxillary prominence,
stitched with silk.
3. 15x6 cm abrasion on vental aspect of left arm
4. 7x5cm abrasion on lateral aspect of left foot behind
lateral malleolus
5. 2.5x1 cm laceration over 2nd MTP joint, stitched with
silk.
 Oropharyngeal airway passed
 2 L Oxygen started.
 B/L equal air entry. NVB + No abdnormal sounds.
 2 18 G IV lines obtained.
 CBC, LFT, RFT, S/E, Coagulation Profile, ABGs, Blood
group and cross match sent.
 Head Protocol given.
 Patient Catheterized.
 ECG obtained.
 Half hourly monitoring started.
 On account of Polytrauma, dangerous mechanism of that
polytrauma, and unavailability of Xray and Ultrasound Facility at
that moment, a decision was made to do a PAN-CT scan.
 CT-Brain : Normal Scan
 HRCT: Normal Scan
 CT-Abdomen and Pelvis: B/L Pelvic bone fracture, sacral
fracture, lumbar spine fracture. Abdominal Findings Largely
inconclusive, Repeat CT with Contrast Advised which was
carried out at 10 pm, finding of which remained inconclusive.
 CT lower limbs: Normal Scan
 Note: All scans were interpreted by G.S team due to
unavailability of radiologist opinion in the ER( which is a norm).
 At the time of arrival of the patient, no radiologist was
avaialable in the Ultrasound Room to carry out FAST
Scan.
 3 Scan were subsequently carried out, all of which were
negative.
1. 8 : 15 pm
2. 10 :30 pm
3. 01 :30 am
 Ortho Team was consulted on arrival, conventional
pelvic binder deemed sufficient.
 0900: After Pan-Scan, Ortho team drilled left sided
traction on tibia. G.S Clearance withheld due to Ortho
apprehensions.
 1100 : After CT-Abd with IV contrast, patient refered to
ortho, pelvic binder attached. Clearance again
withheld due to Ortho concerns.
 Blood Pressure Heart Rate Sao2
140
130 130
120
110 110
100 100 100 100 100 100
90 90
80

60

40

20

0
6pm 7pm 8pm 9pm 10pm 11pm 12am 1am 2am 3am 4am
 Time 04:00 am.
 Rationale :
 Deteriorating Vitals
 Hemoglobin around 11 despite transfusion of 5 units of blood
 Suspected Massive Pelvic Hemorrhage