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

CLINICAL IMPRESSION

• 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)

• Rib contusion / musculoskeletal chest wall injury
• Repeat RR monitoring every 30 min while in ER
• If worsening: CXR, consider pneumothorax

B. SECONDARY SURVEY

• 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 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

• 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)

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

• 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

• 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)

• 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

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

• 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

• Patient Data: Age 36, Sex F | VS: BP 120/80, HR 97 bpm, RR 18 cpm, Temp 36.6°C, O2 Sat 98% RA | Wt/Ht: blank
• Chief Complaint: Abrasion on left knee
• Admitting Impression: 1. Abrasion on left knee

Suggested Completed Slide Content

Notes on the Admitting Impression

1. Multiple abrasions - bilateral knees (not just left)
2. Abrasion - left lower quadrant of abdomen
3. Mechanism: MVA, pedestrian vs. electric bicycle

"Multiple traumatic abrasions, bilateral knees and left lower quadrant of abdomen, secondary to blunt trauma (MVA - pedestrian vs. electric bicycle)"

Two Items Still Missing from the Slide:

1. Weight (Wt) and Height (Ht) - need to be obtained and recorded; important for accurate medication dosing (paracetamol, NSAIDs, Tdap)
2. Tetanus immunization history - this must be elicited if not yet done, as it directly determines prophylaxis orders

Vital Signs — TABOADA, Vicenta | 36/F

Clinical Interpretation

• BP 120/80 - normotensive; no signs of hemodynamic compromise or shock
• HR 97 - borderline; likely due to pain, anxiety, or sympathetic response post-trauma. Monitor for trending upward
• RR 18 - within normal limits, but increased work of breathing was noted on exam - keep under observation
• Temp 36.6°C - afebrile; no systemic inflammatory response at this time (wounds are 8 days old - watch for delayed infection)
• O2 Sat 98% RA - adequate oxygenation on room air; no supplemental oxygen needed currently

Primary Survey — XABCDE Format

X — Exsanguinating Hemorrhage

Finding on this patient: (X) — No exsanguinating hemorrhage

• Check for and control life-threatening external bleeding before anything else
• This patient: No active bleeding noted on exam — CRT <2 sec, SPP, no cyanosis
• Status: Negative / Controlled

A — Airway

Patent, patient able to speak in complete sentences and interact. No hoarseness, no respiratory distress.

• Speaking in full sentences = airway is open and self-maintained
• No hoarseness (rules out laryngeal injury), no gurgling (rules out fluid/blood in airway)
• Status: Clear. No intervention needed.

B — Breathing

Equal chest expansion, clear breath sounds, with increased work of breathing.

• Equal expansion = no tension pneumothorax, no flail chest
• Clear breath sounds bilaterally = no hemothorax, no pneumothorax auscultated
• Increased work of breathing = a flag; could be pain-related (chest wall contusion) or subtle respiratory compromise
• O2 Sat 98% RA is reassuring but monitor closely
• Action: CXR, repeat RR monitoring

C — Circulation

SPP, CRT <2 secs, no cyanosis, no active bleeding noted.

• SPP = Satisfactory Peripheral Perfusion
• CRT <2 sec = adequate tissue perfusion
• No cyanosis, no active bleed
• BP 120/80, HR 97 — hemodynamically stable
• Status: Stable. No resuscitation required at this time.

D — Disability

GCS 15 (E4V5M6). Awake, alert, coherent and oriented to person, time, and place.

• GCS 15 = fully conscious, no neurological deficit
• E4 = opens eyes spontaneously
• V5 = oriented speech
• M6 = obeys commands
• Status: No neurological compromise.

E — Exposure

(+) Abrasion on left knee

• Full exposure and skin survey should be performed (undress the patient, log-roll)
• As noted in the full PE: bilateral knee abrasions + LLQ abdominal abrasion — the slide only lists left knee, which is incomplete
• Correction needed on slide: Should read "(+) Multiple abrasions — bilateral knees and left lower quadrant of abdomen"

Summary Table (Corrected)

Exsanguinating Hemorrhage

Definition

Key Facts

Why It's Checked First (the "X" in XABCDE)

• A patient can bleed to death faster than they can suffocate from an airway problem
• Catastrophic external hemorrhage must be stopped immediately - before anything else
• Examples: a major arterial bleed from the thigh, amputation, or open neck wound

Common Causes

• Major arterial laceration (femoral, brachial, carotid)
• Traumatic amputation
• Penetrating chest/abdominal trauma
• Pelvic fractures (internal)
• Scalp lacerations (especially in children)

Immediate Management

1. Direct manual pressure - first and fastest
2. Tourniquet - for limb bleeding (apply 5-7 cm above wound)
3. Wound packing - for junctional wounds (groin, axilla, neck) where tourniquet cannot be applied
4. Hemostatic agents - gauze impregnated with kaolin (QuikClot) or chitosan
5. Surgical control - if external measures fail

In This Patient

• No active bleeding
• CRT <2 seconds
• BP stable at 120/80
• No visible arterial bleed

SPP and CRT

SPP — Satisfactory Peripheral Perfusion

• Skin color — pink, no pallor or cyanosis
• Skin temperature — warm to touch
• Peripheral pulses — present and strong
• CRT — less than 2 seconds

CRT — Capillary Refill Time

How to Test:

1. Press firmly on the fingernail or fingertip for 5 seconds until it turns white (blanches)
2. Release
3. Count how many seconds until the pink color returns
4. Normal = returns within 2 seconds

In This Patient

• SPP = perfusion is satisfactory
• CRT < 2 seconds = normal capillary refill

AMPLE History — TABOADA, Vicenta | 36/F

A — Allergies

Chicken, egg, shrimp, crabs, eggplant, dried fish

• These are all food allergies
• No drug allergies documented
• Clinical relevance:
  • Egg allergy — note for future influenza vaccines (some are egg-based)
  • Shellfish allergy (shrimp, crabs) — not a contraindication to IV contrast (iodine allergy is separate), but some institutions still screen for it before contrast CT
  • No impact on current medications (paracetamol, Tdap, NSAIDs)

M — Medications

None

• Patient is not on any regular medications
• No anticoagulants, steroids, or immunosuppressants — good, means normal wound healing expected
• No drug interactions to worry about

P — Past Medical History / Previous Illnesses

(-) DM, (-) HPN, (-) Asthma

• Note: Family history is positive for DM (paternal) and HTN (both sides) — patient is at future risk

L — Last Meal / Last Oral Intake

Shells with rice

• Important for anesthesia planning — if procedural sedation or surgery were ever needed, fasting status must be known
• For this patient (wound care only, no sedation planned), less critical but still documented
• "Shells" likely refers to shell-shaped pasta or similar — or possibly shellfish (but patient is allergic to shellfish, so likely pasta)

E — Events / Environment leading to injury

(+) Abrasion on left knee

• This should be expanded on the slide to reflect the full event:
  • Struck from behind by an electric bicycle while standing beside her motorcycle
  • Thrown approximately 2 meters
  • Landed on left knee
  • Immediate burning pain, no loss of consciousness
  • First aid: bandage + cold compress applied

Suggested Correction for Slide 11

E: Struck by e-bike from behind while stationary; thrown ~2 meters; landed on left knee; no LOC; burning pain over left knee; bandage and cold compress applied at scene. DOI: 07/30/2026, 10:00 AM, Tinaan, City of Naga.

PMH — MMASH Format

M — Medical Illnesses

(-) HPN, (-) DM

• No chronic medical conditions
• Asthma also negative (from AMPLE history)
• Clinically significant: no DM = normal wound healing expected; no HPN = no antihypertensive medications to consider

M — Medications

No maintenance medications

• Patient takes no regular/daily medications
• No anticoagulants, steroids, diabetic meds, or antihypertensives
• Safe to prescribe paracetamol, NSAIDs, Tdap without drug interactions

A — Allergies

(blank on slide — needs to be filled in)

A: Food allergies — chicken, egg, shrimp, crabs, eggplant, dried fish. No known drug allergies.

S — Surgeries

No surgeries

• No previous surgical procedures
• No surgical scars or adhesions to consider
• No anesthesia history concerns

H — Hospitalizations

No previous hospitalizations

• This is the patient's first hospital admission
• No prior ER visits, ward admissions, or ICU stays documented

Summary

Action Needed on This Slide:

Physical Examination — TABOADA, Vicenta | 36/F

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 conjunctiva, pink oral mucosa

C/L — Chest/Lungs

Equal chest expansion, clear breath sounds

• Note: Increased work of breathing was noted in the primary survey - this slide does not mention it, so it should be added for completeness

CVS — Cardiovascular System

Regular Rhythm, Normal Rate, DHS (-) Murmurs

Abdomen

Flat, NABS, non-distended, non-tender

• This is reassuring given the LLQ abrasion - the abrasion is superficial with no underlying intra-abdominal pathology detected

What Is Missing from This Slide

Extremities: (+) abrasion on left knee, strong peripheral pulses, CRT <2 seconds, muscle strength 5/5 on all extremities, no limitation of motion

Neuro: GCS 15 (E4V5M6)

Overall PE Interpretation

Final Diagnosis

Primary Diagnosis

• Specifically:
  1. Abrasion, left knee
  2. Abrasion, right knee
  3. Abrasion, left lower quadrant (LLQ) of the abdomen

How to Write It Formally (for the chart/slide)

Final Diagnosis: Multiple traumatic abrasions (bilateral knees and left lower quadrant of abdomen), secondary to blunt trauma — MVA (pedestrian vs. electric bicycle), July 30, 2026

Why "Traumatic Abrasion" and Not Something Else?

Classification of Abrasion Severity

ICD-10 Codes (for reference)

Important Note

+ Infected traumatic abrasion (specify site)

Final Diagnosis (Corrected)

Traumatic Abrasion, Left Knee, secondary to Blunt Force Trauma (MVA — pedestrian vs. electric bicycle), July 30, 2026

Formal Chart Entry

Final Diagnosis: Traumatic abrasion, left knee, secondary to blunt trauma — MVA (pedestrian vs. electric bicycle)

ICD-10 Code

Summary

• Single site — left knee only
• Mechanism — struck from behind by e-bike, thrown ~2 meters, landed on left knee
• No fracture, no neurovascular compromise, no internal injury
• Hemodynamically stable
• Patient is fit for wound care, tetanus prophylaxis, analgesia, and discharge with follow-up