ARDSTrauma - ARDS in Trauma Karl Wagner MD 11/30/04 30 y/o...

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ARDS in Trauma Karl Wagner MD 11/30/04
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30 y/o male (note eyes covered to protect identity)
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2 Dudes (Probably these two)
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CC: s/p MVA HPI: pt 30y/o male in comes to the ED after an MVA with multiple injuries PMHx/PSHx: insignificant Meds: none Allergies: none
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Physcical Exam BP 110/85, HR 115, RR 32 Neuro: in C-collar, GCS 10 (E3V3M4) CVS: tachycardic, Resp/chest: dyspnea, tachypneic, tenderness on right chest, CTA bilat, decreased inspiratory excursion ABD: nondistended, soft, tender in right upper quadrant EXT: 18g IV in left AC and 16g IV right AC, moves all 4 ext, deformity of left thigh, tender to palpation, pulses intact
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Glasgow Coma Scale Eyes spontaneous, command, pain, none Verbal oriented, confused, inappropriate, inconprehensible, none Motor obeys, localizes, withdraws, flex, extension, none
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Physcical Exam BP 110/85, HR 115, RR 32 Neuro: in C-collar, GCS 10 (E3V3M4) CVS: tachycardic, Resp/chest: dyspnea, tachypneic, tenderness on right chest, CTA bilat, decreased inspiratory excursion ABD: nondistended, soft, tender in right upper quadrant EXT: 18g IV in left AC and 16g IV right AC, moves all 4 ext, deformity of left thigh, tender to palpation, pulses intact
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Injury Survey Small subdural hematoma over right frontal lobe Right sided rib fractures 5-8 Lung contusion Liver contusion Left femur fracture
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Operating Room Ventilator 10 cc/kg, 10 Resp/min Isoflurane Arterial line and introducer Four units packed red blood cells Conservative mx for liver Off to SICU for continued mx
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ARDSTrauma - ARDS in Trauma Karl Wagner MD 11/30/04 30 y/o...

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