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Good day doctors, we have a new ER referral patient here in the ER. Patient: 410  TABOADA, VICENTA BRINGCULA Case no: Hospital no.:   Age/Sex: 36/F Marital Status: Married Birthday: 05/18/1990 Address: Malolos, Barili, Cebu Religion: Roman Catholic Contact number: 09694109924   Admitted date: 08/07/26   Primary Service: FAMMED Surgeon Attending Physician: House Ward: CC: abrasions, Left knee NOI: Motor vehicular accident (pedestrian vs. 4-wheel vehicle) POI: Tinaan, City of Naga DOI: 07/30/2026 TOI: 10:00 AM HPI: 17 hours PTC, while preparing to go home, the patient pulled over to the side of the road to inspect her motorcycle wheel. While standing beside her motorcycle, she was struck from behind by an electric bicycle, causing her to be thrown approximately 2 meters and land on her left knee, sustaining abrasions. She immediately experienced a burning pain over the left knee. She denied loss of consciousness. In the interim, the patient coordinated with her insurance provider and was subsequently advised to seek consultation at this institution for further evaluation and management. A: Patent, patient able to speak in complete sentences and interact, No hoarseness, gurgling, no respiratory distress. B: Equal chest expansion, Clear breath sounds, with increased work of breathing C: SPP, CRT <2 secs, no cyanosis, No active bleeding noted. D: GCS 15 (E4V5M6) Awake, alert, coherent and oriented to person, time, place. E: (+) abrasion on left knee PMH: A: chicken, egg, shrimp, shrimps, crabs, eggplant, dried fish M: None P: (-) DM, (-) HPN, (-) Asthma L: shells with rice E: (+) abrasion on left knee applied bandage and cold compress Previous hospitalizations/surgeries: none Drug allergies: None Vaccination: pfizer with booster FAMILY HISTORY Maternal side : (-) DM, (+) HTN, (-) BA, (-) Cancer Paternal side :  (+) DM, (+) HTN, (-) BA, (-) Cancer PERSONAL & SOCIAL HISTORY Job: branch manager Alcohol: Every other month, 500mL per session Smoke: None Drugs: None PE: General: Awake, alert, coherent, not in respiratory distress VS: BP: 120/80 HR: 97 RR: 18 T: 36.6 O2: 98% RA Skin: No rashes, no lesions, no cyanosis, (+) Multiple abrasions both knees, and LLQ of the abdomen. HEENT: Normocephalic, Pupils equal, round, and reactive to light and accommodation, (-) icteric sclera, (-) pale conjunctivae, pink oral mucosa C/L: Equal chest expansion , clear breath sounds CVS: Regular Rythym, Normal Rate, DHS (-) Murmurs Abdomen: Flat, NABS, non-distended, non-tender Extremities:(+) abrasion on left knee, strong peripheral pulses, CRT < 2 seconds. Muscle strength: 5/5 on on all extremeties. No Limitation of motion. Neuro: GCS: 15 (E4V5M6 Traumatic patient give management

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Good. I now have sufficient evidence from the textbooks to compose a thorough, evidence-based management plan. Let me compile the full ER management.

ER Management: TABOADA, Vicenta Bringcula | 36/F | MVA - Pedestrian vs. E-bike

CLINICAL IMPRESSION

Traumatic abrasions, bilateral knees and left lower quadrant of abdomen, secondary to MVA (pedestrian vs. electric bicycle)
  • GCS 15 - hemodynamically stable - no internal signs of injury
  • Low-energy mechanism (e-bike, 2-meter throw), no LOC
  • Multiple abrasions as chief complaint, DOI July 30 (8 days ago) - wound care/infection surveillance is the priority
Note: DOI is July 30, 2026, but consult is August 7 - this means wounds are approximately 8 days old. This is critical for wound management decisions.

A. PRIMARY SURVEY (ATLS Framework)

ComponentFindingAction
A - AirwayPatent, speaks in full sentences, no hoarseness/gurglingMaintained - no intervention needed
B - BreathingEqual chest expansion, clear breath sounds, increased WOB notedMonitor SpO2, reassess - currently 98% RA
C - CirculationBP 120/80, HR 97, SPP, CRT <2s, no active bleedingStable - IV access as clinically indicated
D - DisabilityGCS 15 (E4V5M6), oriented x3No neuro deficit
E - ExposureMultiple abrasions bilat. knees, LLQ abdomenFull skin survey, log-roll exam
Increased work of breathing - although the patient is saturating well and has clear breath sounds, document this carefully. Given MVA mechanism, consider:
  • Rib contusion / musculoskeletal chest wall injury
  • Repeat RR monitoring every 30 min while in ER
  • If worsening: CXR, consider pneumothorax

B. SECONDARY SURVEY

History clarification on arrival:
  • Wounds are 8 days old at time of ER consult (DOI 07/30, admitted 08/07)
  • First aid applied: bandage + cold compress at scene/home
  • Food allergies: chicken, egg, shrimp/crabs, eggplant, dried fish (note for diet and certain medication vehicles)
  • Last meal: shells with rice
  • Vaccination: Pfizer COVID with booster - tetanus status unclear - must be elicited

C. WOUND MANAGEMENT

1. Assessment of Abrasions (8-day-old wounds)

Wounds at 8 days are beyond the primary closure window (typically 6-12 hours for contaminated wounds). Per Tintinalli's Emergency Medicine:
"Wounds older than 6 to 8 hours need aggressive cleansing with strong consideration toward leaving the wound open." - Pfenninger and Fowler's Procedures for Primary Care, p. 1303
Inspect all wounds for:
  • Signs of infection (erythema, warmth, swelling, purulent discharge, increased tenderness)
  • Wound healing progress (are they granulating appropriately?)
  • Embedded road debris / foreign body (common in MVA abrasions)
  • Wound depth - any involvement of deeper structures (tendon, joint capsule)?

2. Wound Cleaning Protocol (per Tintinalli's, Chapter 47)

Order of steps:
  1. Skin disinfection - Chlorhexidine to the surrounding skin (not inside the wound) - allow 2-3 min to dry. Preferred over povidone-iodine per meta-analysis evidence (RR 0.70 for surgical site infections).
  2. Wound irrigation - Copious normal saline irrigation under pressure (20-35 mL syringe + 18G angiocath). Road rash/abrasions from MVA carry high contamination risk (asphalt, debris).
  3. Debridement - Remove any devitalized tissue, embedded gravel, or crust. If the 8-day-old wound is granulating cleanly, gentle debridement to remove loose slough.
  4. Do NOT attempt delayed primary closure at this stage for contaminated road abrasions - allow healing by secondary intention.
  5. Apply non-adherent dressing (e.g., petrolatum gauze or moist saline dressing) + sterile gauze + light bandage.

D. TETANUS PROPHYLAXIS

Per Tintinalli's Emergency Medicine, Table 47-2:
Tetanus Immunization HistoryClean Minor WoundAll Other Wounds (contaminated/abrasion)
<3 or uncertain dosesTd: YES, TIG: NOTd: YES, TIG: YES
≥3 doses, last dose <5yNoneNone
≥3 doses, last dose 5-10yNoneTd only
≥3 doses, last dose >10yTdTd
This patient's MVA abrasion = contaminated wound category.
  • Elicit tetanus vaccination history (Pfizer COVID vaccine noted, tetanus history unknown)
  • If uncertain or <3 doses: give Tdap 0.5 mL IM (deltoid) + Tetanus Immunoglobulin (TIG) 250 units IM (contralateral arm, separate site)
  • Use Tdap (not plain Td) if the patient has never received Tdap as an adult, per current CDC guidelines
  • Tdap preferred in adults who have not had a prior adult Tdap dose

E. ANALGESIA

  • Paracetamol (Acetaminophen) 500-1000 mg PO q6h PRN - first-line for mild-to-moderate pain from abrasions; safe, no allergy concerns noted
  • Ibuprofen 400 mg PO q8h with food PRN (if no contraindications) - NSAIDs are effective for musculoskeletal trauma pain
    • Caution: assess GI tolerance; note no DM/renal disease documented
  • Topical: Lidocaine gel can be applied to abrasion surfaces before wound cleaning to reduce procedural pain

F. ANTIBIOTIC CONSIDERATION

For clean, uncomplicated abrasions healing by secondary intention in an immunocompetent adult with no signs of active infection:
  • Prophylactic antibiotics are NOT routinely indicated for simple abrasions
  • Prescribe antibiotics IF any of the following are present on wound inspection:
    • Signs of local infection (erythema, warmth, purulent discharge, lymphangitis)
    • Deeply embedded foreign material
    • Grossly contaminated wound (soil, feces)
If infection is suspected or confirmed:
  • Amoxicillin-clavulanate 875/125 mg PO q12h x 5-7 days (first choice for contaminated wounds per Tintinalli's, Table 47-1)
  • Alternative (penicillin allergy): Clindamycin + fluoroquinolone

G. DIAGNOSTICS

Given hemodynamic stability and isolated abrasions with low-energy mechanism:
TestIndicationRecommendation
CBCBaseline, exclude anemia/infectionOrder
UrinalysisExclude occult hematuria from abdominal abrasion/flank involvementConsider
Blood glucoseWound healing, family hx DM (paternal)Order
CXRIncreased WOB noted on primary surveyOrder
X-ray left kneeRule out occult fracture - abrasion implies direct impactOrder
X-ray bilateral kneesBilateral abrasion notedOrder if clinically indicated

H. DISPOSITION PLAN

  1. Wound re-dressing instruction - educate patient on daily wound care at home
  2. Return precautions - instruct patient to return if: fever >38°C, increasing redness/swelling/pus, wound dehiscence, or worsening pain
  3. Follow-up - in 48-72 hours for wound check (or earlier if signs of infection)
  4. Ortho/FAMMED coordination - as the primary service is Family Medicine, loop in ortho only if X-ray reveals bony involvement
  5. Discharge medications:
    • Paracetamol 500 mg PO q6h PRN pain (3-5 days)
    • Cetirizine or loratadine if pruritus develops over healing abrasion (avoid in allergy patients - confirm seafood/food allergy unrelated to antihistamine vehicles)
    • Topical antiseptic + non-adherent dressing supplies for home wound care
    • Amoxicillin-clavulanate only if signs of wound infection present on inspection

I. ALLERGY ALERT REMINDER

Patient has documented food allergies: chicken, egg, shrimp, crabs, eggplant, dried fish.
  • No drug allergies noted
  • Cross-reactivity with shellfish is not a contraindication to most medications, but be cautious with glucosamine supplements (shellfish-derived) if ever considered
  • Egg allergy: note for any future influenza vaccination (current ER visit: not directly relevant)

SUMMARY ORDER SHEET

ORDERS - TABOADA, Vicenta | 36/F | DOA 08/07/26

DIAGNOSTICS:
[ ] CXR PA view (increased WOB)
[ ] X-ray Left Knee AP/Lateral
[ ] CBC with differential
[ ] Blood glucose (RBS)
[ ] Urinalysis

WOUND CARE:
[ ] Wound inspection all abrasion sites
[ ] Chlorhexidine skin disinfection - surrounding skin
[ ] Copious NS irrigation under pressure
[ ] Gentle debridement of slough/debris
[ ] Non-adherent dressing (petrolatum gauze) + sterile gauze + wrap
[ ] Wound recheck in 48-72 hours

TETANUS:
[ ] Elicit full tetanus vaccination history
[ ] If uncertain/incomplete: Tdap 0.5 mL IM deltoid
[ ] If contaminated wound + uncertain hx: TIG 250 units IM (contralateral arm)

MEDICATIONS:
[ ] Paracetamol 500-1000 mg PO q6h PRN (mild-to-moderate pain)
[ ] Ibuprofen 400 mg PO q8h with food PRN (if no contraindications)
[ ] Amoxicillin-clavulanate 875/125 mg PO q12h x 5-7 days 
    (ONLY if wound infection signs present on inspection)

DISPOSITION:
[ ] Discharge to home with wound care instructions
[ ] Return precautions discussed: fever, increased redness/swelling/pus, 
    worsening pain
[ ] Follow-up FAMMED OPD in 48-72 hours for wound check
[ ] Ortho referral if X-ray shows bony pathology
Sources: Tintinalli's Emergency Medicine - A Comprehensive Study (wound preparation, tetanus prophylaxis tables); Pfenninger and Fowler's Procedures for Primary Care 3rd ed (wound management, tetanus decision tree); ATLS Primary Survey principles (Schwartz's Principles of Surgery 11th ed)
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