Traumatic Disorders

A 28-year-old woman at 30 weeks' gestation is brought to the emergency department by ambulance after a head-on motor vehicle collision. She was the restrained driver and airbags deployed. She complains of abdominal pain and reports fetal movements have felt reduced since the crash. On examination she is alert with GCS 15, BP 108/68 mmHg, HR 108 bpm, RR 20/min, SpO2 97% on room air. There is a linear bruise across the lower abdomen consistent with lap-belt placement, and the uterine fundus is tender but the abdomen is otherwise soft. Cardiotocography shows a baseline fetal heart rate of 140 bpm with recurrent late decelerations. There is no vaginal bleeding and no signs of external haemorrhage. Which of the following is the most important initial intervention?

A 26-year-old man is brought to the emergency department after a high-speed motor vehicle collision in which he was a restrained front-seat passenger. He is haemodynamically stable with a GCS of 15 and reports neck pain and a mild headache, but no focal neurological deficit is found on examination. A seatbelt sign is noted across the anterolateral neck. CT angiography of the neck demonstrates an isolated left internal carotid artery dissection with a patent lumen, no associated pseudoaneurysm, and no evidence of cerebral infarction on CT brain. There are no other significant injuries. Neurosurgery and vascular surgery are consulted and do not recommend intervention at this stage. What is the most appropriate antithrombotic management for this patient?

A 28-year-old rock climber is extricated after being trapped under a boulder for approximately 5 hours, with his right thigh and lower leg compressed throughout. On arrival he is tachycardic (HR 118 bpm), BP 110/70 mmHg, and alert but distressed with severe pain in the affected limb. The right thigh and calf are tensely swollen, the skin is intact but shiny, and passive dorsiflexion of the foot is impossible with the patient screaming in pain on passive stretch. Distal pulses are palpable, capillary refill is 3 seconds, and there is patchy sensory loss over the dorsum of the foot. Urine is dark tea-coloured. Needle manometry of the anterior compartment reads 45 mmHg. Bloods are pending but bedside venous gas shows K+ 5.8 mmol/L and a rising creatinine kinase. What is the most appropriate management?

A 24-year-old man is brought to a small rural emergency department by ambulance after his vehicle rolled several times on a rural highway, with 35 minutes required for extrication by fire crews. On arrival his vital signs are HR 104/min, BP 118/76 mmHg, RR 18/min, and SpO2 98% on room air. His GCS is 13 (E3V4M6). Primary and secondary survey reveal an isolated closed deformity of the right thigh consistent with a femoral shaft fracture, with no chest wall tenderness, abdominal tenderness, or pelvic instability, and a negative FAST scan. Plain films confirm an isolated closed femoral shaft fracture with no other injuries identified. The treating clinician is deciding whether this patient meets criteria for transfer to a designated trauma centre.

A 24-year-old man is brought to the emergency department by paramedics after diving into shallow water at the beach and striking his head on the sandy bottom. He is awake and alert, complaining of severe neck pain and paraesthesiae radiating into both arms. He denies loss of consciousness. On examination he has bilateral upper limb weakness (power 3/5 proximally and distally), reduced power in the lower limbs, and a heart rate of 52 beats/min with a blood pressure of 88/54 mmHg; his chest is clear and he is maintaining his own airway. A rigid cervical collar has already been applied by the paramedics, and CT of the cervical spine confirms a fracture at C2 with cord compromise. He is being transferred to theatre for urgent stabilisation. Which of the following is the most appropriate position for this patient during transfer?

A 70-year-old woman is brought to the emergency department after a mechanical fall at home. She has a background of ischaemic heart disease, hypertension and stage 3 chronic kidney disease (baseline creatinine 140 micromol/L). She reports severe right hip pain and is unable to weight-bear. On examination the right leg is shortened and externally rotated, with tenderness over the groin and no distal neurovascular deficit. Vital signs are BP 148/86 mmHg, HR 98 bpm, RR 18/min, SpO2 96% on room air, and pain score 9/10. Pelvic X-ray confirms a displaced, isolated intracapsular femoral neck fracture with no other injury. She is due for early orthopaedic fixation. Which of the following analgesic strategies is most appropriate for this patient while she awaits theatre?