A case of comprehensive nursing management of severe polytrauma following a road traffic accident
Uma.P1*, Subathra Devi. M2, Maha Lakshmi3
1Nursing Supervisor, Kauvery Hospital, Cantonment, Trichy, Tamil Nadu
2Nurse Educator, Kauvery Hospital, Cantonment, Trichy, Tamil Nadu
3Nursing Superintendent, Kauvery Hospital, Cantonment, Trichy, Tamil Nadu
*Correspondence
Abstract
A patient involved in a road traffic accident on 04.05.2026 sustained severe head and chest injuries. He had a low GCS, bilateral pneumothorax, lung contusion, pneumomediastinum, subcutaneous emphysema, and grade III diffuse axonal injury. Emergency bilateral ICD insertion and mechanical ventilation were provided. Due to prolonged ventilation, tracheostomy was performed. During the hospital stay, the patient developed respiratory infection, right pleural effusion, and airway complications, which were managed appropriately with multidisciplinary care. Gradual ventilator weaning and airway management were continued, followed by coblation-assisted balloon dilatation. The patient was successfully decannulated on 24.06.2026, tolerated oral feeds and spontaneous breathing, and was discharged in a clinically improved condition.
Key words: Bilateral pneumothorax; Road traffic accident; Loss of consciousness (LOC)
Introduction
Road traffic accidents can cause severe head and chest injuries and may require prolonged critical care. Early airway management, treatment of pneumothorax, mechanical ventilation, and continuous monitoring are important for recovery. This case describes the management of a patient with severe traumatic brain injury and chest trauma who required prolonged ventilation, tracheostomy, treatment of respiratory complications, gradual weaning, and successful decannulation.
Case Presentation
The patient was involved in a Road Traffic Accident (RTA) on 04.05.2026 at approximately 4:00 PM, following which he sustained head and chest injuries. There was a history of loss of consciousness (LOC), left-sided nasal bleeding, right ear bleeding, oral bleeding, nausea, vomiting, and seizure activity. He was initially treated at an outside hospital, where he was intubated in view of a low Glasgow Coma Scale (GCS) score and the risk of aspiration.
Relevant Clinical Findings
| Social History | Nil |
|---|---|
| Allergies | Nil |
| Past Medical History | Nil |
| Past Surgical history | Nil |
Physical Examinations
| Patient GCS | E1 VT M1 |
| Pupils | Bilateral 2.5mmRTL |
| PR | 126/min |
| BP | 120/80mmHg |
| SpO2 | 77% with FiO2 100% |
| RS | Decreased air entry in bilateral lung fields |
| CNS | No motor response to pain, no eye opening to pain |
Extensive subcutaneous emphysema throughout the body
Relevant Investigation
| Investigation Name | Result | Test Date Time |
|---|---|---|
| Sodium | 135 mmol/L | 01-06-26 05:29:01 |
| Creatinine | 0.9 mg/dL | 01-06-26 05:29:01 |
| Phosphorous | 4.8 mg/dL | 01-06-26 05:29:01 |
| Urea Serum | 17 mg/dL | 01-06-26 05:29:01 |
| Calcium Serum | 8.9 mg/dL | 01-06-26 05:29:01 |
| Potassium | 4.2 mmol/L | 01-06-26 05:29:01 |
| Magnesium | 1.6 mg/dL | 01-06-26 05:29:01 |
| Glucose In Glucometer POCT | 105 mg/dL | 01-06-26 06:46:45 |
| K + | 4.4 mmol/L | 01-06-26 07:39:01 |
| BE(B) | 2.1 mm Hg | 01-06-26 07:39:01 |
| HCO3(c) | 25.1 mmol/L | 01-06-26 07:39:01 |
| Chloride Blood | 102 mEq/L | 01-06-26 07:39:01 |
| O2Sat | 98.2 % | 01-06-26 07:39:01 |
| PCO2 | 33 mm Hg | 01-06-26 07:39:01 |
| Glucose | 109 mg/dL | 01-06-26 07:39:01 |
| pH Blood | 7.49 NA | 01-06-26 07:39:01 |
| HCO3(c) | 26.6 mmol/L | 02-06-26 06:46:02 |
| O2Sat | 98.3 % | 02-06-26 06:46:02 |
| Chloride Blood | 103 mEq/L | 02-06-26 06:46:02 |
| Glucose | 119 mg/dL | 02-06-26 06:46:02 |
| pH Blood | 7.41 NA | 02-06-26 06:46:02 |
| PCO2 | 42 mm Hg | 02-06-26 06:46:02 |
| BE(B) | 1.7 mm Hg | 02-06-26 06:46:02 |
| K + | 3.7 mmol/L | 02-06-26 06:46:02 |
| Total Bilirubin | 0.8 mg/dL | 04-05-26 20:48:01 |
| Indirect Bilirubin | 0.3 mg/dL | 04-05-26 20:48:01 |
| Urine Nitrite | Negative | 04-05-26 23:58:01 |
| Chloride Blood | 103 mEq/L | 04-06-26 20:14:08 |
| Troponin T | Negative | 07-05-26 11:03:59 |
| Sodium | 136 mmol/L | 11-05-26 03:01:01 |
| Creatinine | 0.8 mg/dL | 11-05-26 03:01:01 |
| Urea Serum | 46 mg/dL | 11-05-26 03:01:01 |
| Potassium | 4.4 mmol/L | 11-05-26 03:01:01 |
| Magnesium | 1.7 mg/dL | 11-05-26 03:01:01 |
| Phosphorous | 3.2 mg/dL | 11-05-26 03:01:01 |
| Protein Serum | 5.2 g/dl | 18-05-26 17:16:02 |
| Albumin, Serum | 2.4 g/dl | 18-05-26 17:16:02 |
| Lactate Dehydrogenase (LDH) Pleural Fluid | 5430 | 18-05-26 17:58:51 |
| Pleural Fluid Protein | 3.7 | 18-05-26 17:58:51 |
| Fluid For Sugar | 20 . | 18-05-26 17:58:51 |
| Albumin Fluid | 1.7 | 18-05-26 17:58:51 |
| Packed Cell Volume (PCV) | 32.0 % | 01-06-26 06:14:01 |
| Haemoglobin | 10.4 g/dl | 01-06-26 06:14:01 |
| Total WBC Count | 15240 Cells/Cumm | 01-06-26 06:14:01 |
| Absolute Lymphocyte Count (ALC) | 1910 cells/µl | 01-06-26 06:14:01 |
| Platelet Count | 542000 cells/µl | 01-06-26 06:14:01 |
| Absolute Eosinophil Count (AEC) | 140 cells/µl | 01-06-26 06:14:01 |
| Mean Platelet Volume (MPV) | 9.0 NA | 01-06-26 06:14:01 |
| Total RBC Count | 3.56 ML/10^9 | 01-06-26 06:14:01 |
| Monocyte | 9.6 % | 01-06-26 06:14:01 |
| (MCH) Mean Corpuscular Haemoglobin | 29.2 pg/cell | 01-06-26 06:14:01 |
| (MCHC) Mean Corpuscular Haemoglobin Concentration | 32.5 g/dl | 01-06-26 06:14:01 |
| Absolute Monocyte Count (AMC) | 1460 cells/µl | 01-06-26 06:14:01 |
| Neutrophil | 76.7 % | 01-06-26 06:14:01 |
| Absolute Neutrophil Count (ANC) | 11690 cells/µl | 01-06-26 06:14:01 |
| Lymphocyte | 12.5 % | 01-06-26 06:14:01 |
| Mean Corpuscular Volume (MCV) | 89.9 | 01-06-26 06:14:01 |
| Haematocrit | 36 % | 01-06-26 07:39:01 |
| Haematocrit | 35 % | 02-06-26 06:46:02 |
| Haematocrit | 44 % | 04-05-26 18:19:01 |
| (MCH) Mean Corpuscular Haemoglobin | 31.3 pg/cell | 04-05-26 19:53:01 |
| Mean Corpuscular Volume (MCV) | 93.6 | 04-05-26 19:53:01 |
| Total WBC Count | 14020 Cells/Cumm | 04-05-26 19:53:01 |
| Platelet Count | 234000 cells/µl | 04-05-26 19:53:01 |
| Test (PT) | 12.0 Seconds | 04-05-26 19:53:01 |
| Monocyte | 6.8 % | 04-05-26 19:53:01 |
| Neutrophil | 65.5 % | 04-05-26 19:53:01 |
| Test (APTT) | 22.6 Seconds | 04-05-26 19:53:01 |
| Absolute Neutrophil Count (ANC) | 9190 cells/µl | 04-05-26 19:53:01 |
| Absolute Monocyte Count (AMC) | 950 cells/µl | 04-05-26 19:53:01 |
| Basophil | 0.4 % | 04-05-26 19:53:01 |
| Mean Platelet Volume (MPV) | 10.0 NA | 04-05-26 19:53:01 |
| Total RBC Count | 4.99 ML/10^9 | 04-05-26 19:53:01 |
| Haemoglobin | 15.6 g/dl | 04-05-26 19:53:01 |
| (MCHC) Mean Corpuscular Haemoglobin Concentration | 33.4 g/dl | 04-05-26 19:53:01 |
| Lymphocyte | 26.8 % | 04-05-26 19:53:01 |
| Packed Cell Volume (PCV) | 46.7 % | 04-05-26 19:53:01 |
| Absolute Eosinophil Count (AEC) | 70 cells/µl | 04-05-26 19:53:01 |
| Absolute Lymphocyte Count (ALC) | 3760 cells/µl | 04-05-26 19:53:01 |
| Control (PT) | 10.7 Seconds | 04-05-26 20:18:48 |
| Control (APTT) | 27.0 Seconds | 04-05-26 20:18:48 |
| Haematocrit | 35 % | 04-06-26 20:14:08 |
| Haematocrit | 40 % | 05-05-26 00:43:01 |
| Haematocrit | 41 % | 05-05-26 17:18:02 |
| Haematocrit | 43 % | 06-05-26 16:35:08 |
| Haematocrit | 35 % | 06-06-26 08:32:02 |
| Basophil | 0.6 % | 07-05-26 04:54:27 |
| Absolute Monocyte Count (AMC) | 170 cells/µl | 07-05-26 04:54:27 |
| Absolute Neutrophil Count (ANC) | 2990 cells/µl | 07-05-26 04:54:27 |
| Test (APTT) | 36.3 Seconds | 07-05-26 04:54:27 |
| Neutrophil | 86.7 % | 07-05-26 04:54:27 |
| Monocyte | 4.9 % | 07-05-26 04:54:27 |
| Test (PT) | 14.1 Seconds | 07-05-26 04:54:27 |
| Mean Platelet Volume (MPV) | 9.6 NA | 07-05-26 04:54:27 |
| Platelet Count | 104000 cells/µl | 07-05-26 04:54:27 |
| Total WBC Count | 3450 Cells/Cumm | 07-05-26 04:54:27 |
| Mean Corpuscular Volume (MCV) | 92.9 | 07-05-26 04:54:27 |
| (MCH) Mean Corpuscular Haemoglobin | 30.5 pg/cell | 07-05-26 04:54:27 |
| Absolute Lymphocyte Count (ALC) | 270 cells/µl | 07-05-26 04:54:27 |
| Absolute Eosinophil Count (AEC) | 0 cells/µl | 07-05-26 04:54:27 |
| Packed Cell Volume (PCV) | 42.9 % | 07-05-26 04:54:27 |
| Lymphocyte | 7.8 % | 07-05-26 04:54:27 |
| (MCHC) Mean Corpuscular Haemoglobin Concentration | 32.9 g/dl | 07-05-26 04:54:27 |
| Haemoglobin | 14.1 g/dl | 07-05-26 04:54:27 |
| Total RBC Count | 4.62 ML/10^9 | 07-05-26 04:54:27 |
| Control (APTT) | 27.0 Seconds | 07-05-26 06:23:44 |
| Control (PT) | 10.7 Seconds | 07-05-26 06:23:44 |
| Haematocrit | 44 % | 07-05-26 07:42:01 |
| Haematocrit | 36 % | 07-05-26 12:43:04 |
| Haematocrit | 42 % | 07-05-26 18:14:01 |
| Haematocrit | 37 % | 07-05-26 23:12:01 |
| Haematocrit | 33 % | 08-05-26 06:25:01 |
| Haemoglobin | 8.4 g/dl | 08-05-26 14:43:05 |
| Packed Cell Volume (PCV) | 25.4 % | 08-05-26 14:43:05 |
| Lymphocyte | 11.1 % | 08-05-26 14:43:05 |
| Neutrophil | 82.8 % | 08-05-26 14:43:05 |
| Mean Corpuscular Volume (MCV) | 92.7 | 08-05-26 14:43:05 |
| Absolute Neutrophil Count (ANC) | 3970 cells/µl | 08-05-26 14:43:05 |
| (MCH) Mean Corpuscular Haemoglobin | 30.7 pg/cell | 08-05-26 14:43:05 |
| (MCHC) Mean Corpuscular Haemoglobin Concentration | 33.1 g/dl | 08-05-26 14:43:05 |
| Total RBC Count | 2.74 ML/10^9 | 08-05-26 14:43:05 |
| Absolute Lymphocyte Count (ALC) | 530 cells/µl | 08-05-26 14:43:05 |
| Monocyte | 4.4 % | 08-05-26 14:43:05 |
| Total WBC Count | 4790 Cells/Cumm | 08-05-26 14:43:05 |
| Absolute Monocyte Count (AMC) | 210 cells/µl | 08-05-26 14:43:05 |
| Basophil | 0.0 % | 08-05-26 14:43:05 |
| Mean Platelet Volume (MPV) | 9.9 NA | 08-05-26 14:43:05 |
| Absolute Eosinophil Count (AEC) | 80 cells/µl | 08-05-26 14:43:05 |
| Platelet Count | 108000 cells/µl | 08-05-26 14:43:05 |
| Haematocrit | 34 % | 09-05-26 00:24:01 |
| Haematocrit | 32 % | 09-05-26 15:04:02 |
| (MCH) Mean Corpuscular Haemoglobin | 30.6 pg/cell | 09-05-26 15:47:01 |
| Mean Corpuscular Volume (MCV) | 92.8 | 09-05-26 15:47:01 |
| Total WBC Count | 6410 Cells/Cumm | 09-05-26 15:47:01 |
| Platelet Count | 120000 cells/µl | 09-05-26 15:47:01 |
| Mean Platelet Volume (MPV) | 9.7 NA | 09-05-26 15:47:01 |
| (MCHC) Mean Corpuscular Haemoglobin Concentration | 33.0 g/dl | 09-05-26 15:47:01 |
| Lymphocyte | 5.8 % | 09-05-26 15:47:01 |
| Packed Cell Volume (PCV) | 29.7 % | 09-05-26 15:47:01 |
| Absolute Eosinophil Count (AEC) | 110 cells/µl | 09-05-26 15:47:01 |
| Absolute Lymphocyte Count (ALC) | 370 cells/µl | 09-05-26 15:47:01 |
| Total RBC Count | 3.20 ML/10^9 | 09-05-26 15:47:01 |
| Monocyte | 10.5 % | 09-05-26 15:47:01 |
| Haemoglobin | 9.8 g/dl | 09-05-26 15:47:01 |
| Neutrophil | 81.8 % | 09-05-26 15:47:01 |
| Absolute Neutrophil Count (ANC) | 5250 cells/µl | 09-05-26 15:47:01 |
| Absolute Monocyte Count (AMC) | 670 cells/µl | 09-05-26 15:47:01 |
| Basophil | 0.2 % | 09-05-26 15:47:01 |
| Haemoglobin | 11.8 g/dl | 09-06-26 21:07:01 |
| Packed Cell Volume (PCV) | 36.9 % | 09-06-26 21:07:01 |
| Platelet Count | 355000 cells/µl | 09-06-26 21:07:01 |
| Test (APTT) | 28.5 Seconds | 09-06-26 21:20:23 |
| Control (APTT) | 26.6 Seconds | 09-06-26 21:20:23 |
| Test (PT) | 12.7 Seconds | 09-06-26 21:20:23 |
| Control (PT) | 10.7 Seconds | 09-06-26 21:20:23 |
| Haematocrit | 37 % | 10-05-26 08:10:01 |
| Haematocrit | 34 % | 10-05-26 20:22:01 |
| Platelet Count | 174000 cells/µl | 11-05-26 03:01:01 |
| Absolute Neutrophil Count (ANC) | 9510 cells/µl | 11-05-26 03:01:01 |
| Monocyte | 10.4 % | 11-05-26 03:01:01 |
| Absolute Monocyte Count (AMC) | 1220 cells/µl | 11-05-26 03:01:01 |
| Absolute Eosinophil Count (AEC) | 90 cells/µl | 11-05-26 03:01:01 |
| Basophil | 0.3 % | 11-05-26 03:01:01 |
| Neutrophil | 81.2 % | 11-05-26 03:01:01 |
| Total RBC Count | 3.83 ML/10^9 | 11-05-26 03:01:01 |
| Mean Corpuscular Volume (MCV) | 93.2 | 11-05-26 03:01:01 |
| Lymphocyte | 7.3 % | 11-05-26 03:01:01 |
| Total WBC Count | 11710 Cells/Cumm | 11-05-26 03:01:01 |
| (MCH) Mean Corpuscular Haemoglobin | 30.8 pg/cell | 11-05-26 03:01:01 |
| Absolute Lymphocyte Count (ALC) | 860 cells/µl | 11-05-26 03:01:01 |
| (MCHC) Mean Corpuscular Haemoglobin Concentration | 33.1 g/dl | 11-05-26 03:01:01 |
| Haemoglobin | 11.8 g/dl | 11-05-26 03:01:01 |
| Mean Platelet Volume (MPV) | 9.8 NA | 11-05-26 03:01:01 |
| Packed Cell Volume (PCV) | 35.7 % | 11-05-26 03:01:01 |
| Control (APTT) | 27.0 Seconds | 11-05-26 03:40:01 |
| Test (PT) | 12.9 Seconds | 11-05-26 03:40:01 |
| Control (PT) | 10.7 Seconds | 11-05-26 03:40:01 |
| Test (APTT) | 31.1 Seconds | 11-05-26 03:40:01 |
| Fibrinogen | 525 mg/dL | 11-05-26 03:47:34 |
| Haematocrit | 38 % | 11-05-26 08:09:01 |
| Haematocrit | 18 % | 11-05-26 17:58:01 |
| Test (APTT) | 34.5 Seconds | 12-05-26 08:45:01 |
| Test (PT) | 14.1 Seconds | 12-05-26 08:45:01 |
| Control (APTT) | 27.0 Seconds | 12-05-26 09:36:54 |
| Control (PT) | 10.7 Seconds | 12-05-26 09:36:54 |
| Haematocrit | 31 % | 12-05-26 21:40:01 |
| Absolute Neutrophil Count (ANC) | 6760 cells/µl | 12-06-26 06:09:01 |
| Absolute Monocyte Count (AMC) | 730 cells/µl | 12-06-26 06:09:01 |
| Basophil | 0.2 % | 12-06-26 06:09:01 |
| (MCH) Mean Corpuscular Haemoglobin | 28.5 pg/cell | 12-06-26 06:09:01 |
| Mean Corpuscular Volume (MCV) | 92.9 | 12-06-26 06:09:01 |
| Total WBC Count | 9740 Cells/Cumm | 12-06-26 06:09:01 |
| Platelet Count | 309000 cells/µl | 12-06-26 06:09:01 |
| Mean Platelet Volume (MPV) | 9.1 NA | 12-06-26 06:09:01 |
| Monocyte | 7.5 % | 12-06-26 06:09:01 |
| (MCHC) Mean Corpuscular Haemoglobin Concentration | 30.7 g/dl | 12-06-26 06:09:01 |
| Lymphocyte | 21.9 % | 12-06-26 06:09:01 |
| Packed Cell Volume (PCV) | 34.2 % | 12-06-26 06:09:01 |
| Absolute Eosinophil Count (AEC) | 100 cells/µl | 12-06-26 06:09:01 |
| Absolute Lymphocyte Count (ALC) | 2130 cells/µl | 12-06-26 06:09:01 |
| Total RBC Count | 3.68 10^6/µL | 12-06-26 06:09:01 |
| Neutrophil | 69.4 % | 12-06-26 06:09:01 |
| Haemoglobin | 10.5 g/dl | 12-06-26 06:09:01 |
| Haematocrit | 27 % | 13-05-26 10:56:01 |
| Haemoglobin | 10.0 g/dl | 16-05-26 17:24:01 |
| Total RBC Count | 3.26 ML/10^9 | 16-05-26 17:24:01 |
| Absolute Lymphocyte Count (ALC) | 1160 cells/µl | 16-05-26 17:24:01 |
| Absolute Eosinophil Count (AEC) | 40 cells/µl | 16-05-26 17:24:01 |
| Packed Cell Volume (PCV) | 30.4 % | 16-05-26 17:24:01 |
| Lymphocyte | 3.8 % | 16-05-26 17:24:01 |
| (MCHC) Mean Corpuscular Haemoglobin Concentration | 32.9 g/dl | 16-05-26 17:24:01 |
| Monocyte | 6.8 % | 16-05-26 17:24:01 |
| Mean Platelet Volume (MPV) | 9.7 NA | 16-05-26 17:24:01 |
| Platelet Count | 537000 cells/µl | 16-05-26 17:24:01 |
| Total WBC Count | 30630 Cells/Cumm | 16-05-26 17:24:01 |
| Mean Corpuscular Volume (MCV) | 93.3 | 16-05-26 17:24:01 |
| (MCH) Mean Corpuscular Haemoglobin | 30.7 pg/cell | 16-05-26 17:24:01 |
| Basophil | 0.1 % | 16-05-26 17:24:01 |
| Absolute Monocyte Count (AMC) | 2090 cells/µl | 16-05-26 17:24:01 |
| Absolute Neutrophil Count (ANC) | 27300 cells/µl | 16-05-26 17:24:01 |
| Neutrophil | 89.2 % | 16-05-26 17:24:01 |
| Mean Platelet Volume (MPV) | 9.0 NA | 19-06-26 15:14:03 |
| Mean Corpuscular Volume (MCV) | 93.4 | 19-06-26 15:14:03 |
| Monocyte | 5.3 % | 19-06-26 15:14:03 |
| Neutrophil | 81.9 % | 19-06-26 15:14:03 |
| Platelet Count | 350000 cells/µl | 19-06-26 15:14:03 |
| Total RBC Count | 4.73 10^6/µL | 19-06-26 15:14:03 |
| Lymphocyte | 12.2 % | 19-06-26 15:14:03 |
| Total WBC Count | 12430 Cells/Cumm | 19-06-26 15:14:03 |
| Absolute Monocyte Count (AMC) | 660 cells/µl | 19-06-26 15:14:03 |
| Packed Cell Volume (PCV) | 44.2 % | 19-06-26 15:14:03 |
| (MCH) Mean Corpuscular Haemoglobin | 29.2 pg/cell | 19-06-26 15:14:03 |
| Absolute Neutrophil Count (ANC) | 10180 cells/µl | 19-06-26 15:14:03 |
| Basophil | 0.2 % | 19-06-26 15:14:03 |
| (MCHC) Mean Corpuscular Haemoglobin Concentration | 31.2 g/dl | 19-06-26 15:14:03 |
| Absolute Lymphocyte Count (ALC) | 1520 cells/µl | 19-06-26 15:14:03 |
| Haemoglobin | 13.8 g/dl | 19-06-26 15:14:03 |
| Absolute Eosinophil Count (AEC) | 50 cells/µl | 19-06-26 15:14:03 |
| Haematocrit | 34 % | 20-05-26 12:48:01 |
| Haematocrit | 26 % | 20-05-26 23:28:01 |
| Mean Platelet Volume (MPV) | 9.7 NA | 21-05-26 06:16:02 |
| Monocyte | 10.5 % | 21-05-26 06:16:02 |
| (MCHC) Mean Corpuscular Haemoglobin Concentration | 32.5 g/dl | 21-05-26 06:16:02 |
| Lymphocyte | 13.0 % | 21-05-26 06:16:02 |
| Packed Cell Volume (PCV) | 27.1 % | 21-05-26 06:16:02 |
| Absolute Eosinophil Count (AEC) | 100 cells/µl | 21-05-26 06:16:02 |
| Absolute Lymphocyte Count (ALC) | 2080 cells/µl | 21-05-26 06:16:02 |
| (MCH) Mean Corpuscular Haemoglobin | 30.1 pg/cell | 21-05-26 06:16:02 |
| Total RBC Count | 2.92 ML/10^9 | 21-05-26 06:16:02 |
| Haemoglobin | 8.8 g/dl | 21-05-26 06:16:02 |
| Neutrophil | 75.7 % | 21-05-26 06:16:02 |
| Absolute Neutrophil Count (ANC) | 12140 cells/µl | 21-05-26 06:16:02 |
| Absolute Monocyte Count (AMC) | 1680 cells/µl | 21-05-26 06:16:02 |
| Basophil | 0.2 % | 21-05-26 06:16:02 |
| Mean Corpuscular Volume (MCV) | 92.8 | 21-05-26 06:16:02 |
| Total WBC Count | 16030 Cells/Cumm | 21-05-26 06:16:02 |
| Platelet Count | 567000 cells/µl | 21-05-26 06:16:02 |
| Haematocrit | 27 % | 24-05-26 16:01:01 |
| Haematocrit | 34 % | 25-05-26 11:14:02 |
| Packed Cell Volume (PCV) | 31.9 % | 26-05-26 12:36:03 |
| Mean Platelet Volume (MPV) | 8.4 NA | 26-05-26 12:36:03 |
| (MCHC) Mean Corpuscular Haemoglobin Concentration | 32.6 g/dl | 26-05-26 12:36:03 |
| Mean Corpuscular Volume (MCV) | 90.6 | 26-05-26 12:36:03 |
| Total RBC Count | 3.52 ML/10^9 | 26-05-26 12:36:03 |
| Absolute Eosinophil Count (AEC) | 80 cells/µl | 26-05-26 12:36:03 |
| Absolute Lymphocyte Count (ALC) | 1810 cells/µl | 26-05-26 12:36:03 |
| Haemoglobin | 10.4 g/dl | 26-05-26 12:36:03 |
| Basophil | 0.3 % | 26-05-26 12:36:03 |
| (MCH) Mean Corpuscular Haemoglobin | 29.5 pg/cell | 26-05-26 12:36:03 |
| Absolute Monocyte Count (AMC) | 1910 cells/µl | 26-05-26 12:36:03 |
| Neutrophil | 81.4 % | 26-05-26 12:36:03 |
| Lymphocyte | 8.7 % | 26-05-26 12:36:03 |
| Total WBC Count | 20760 Cells/Cumm | 26-05-26 12:36:03 |
| Absolute Neutrophil Count (ANC) | 16900 cells/µl | 26-05-26 12:36:03 |
| Monocyte | 9.2 % | 26-05-26 12:36:03 |
| Platelet Count | 774000 cells/µl | 26-05-26 12:36:03 |
| Haematocrit | 30 % | 30-05-26 14:51:02 |
| Haematocrit | 32 % | 31-05-26 09:16:01 |
| Absolute Basophil Count (ABC) | 40 cells/µl | 01-06-26 06:14:01 |
| RDW - CV | 13.0 % | 01-06-26 06:14:01 |
| Eosinophil | 0.9 % | 01-06-26 06:14:01 |
| Eosinophil | 1.7 % | 09-05-26 15:47:01 |
| Absolute Basophil Count (ABC) | 10 cells/µl | 09-05-26 15:47:01 |
| INR | 1.19 . | 09-06-26 21:20:23 |
| Absolute Basophil Count (ABC) | 30 cells/µl | 11-05-26 03:01:01 |
| Eosinophil | 0.8 % | 11-05-26 03:01:01 |
| RDW - CV | 12.8 % | 11-05-26 03:01:01 |
| INR | 1.22 . | 11-05-26 03:40:01 |
| INR | 1.33 . | 12-05-26 08:45:01 |
| Absolute Basophil Count (ABC) | 60 cells/µl | 26-05-26 12:36:03 |
| RDW - CV | 13.3 % | 26-05-26 12:36:03 |
| C Reactive Protein (CRP) | 303.4 mg/L | 16-05-26 17:24:01 |
| C Reactive Protein (CRP) | 57.0 mg/L | 26-05-26 12:36:03 |
| NA+ | 129 mmol/L | 01-06-26 07:39:01 |
| PO2 | 116 mm Hg | 01-06-26 07:39:01 |
| CA++(7.4) | 1.18 mmol/L | 01-06-26 07:39:01 |
| Lac | 1.0 mmol/L | 01-06-26 07:39:01 |
| PO2 | 148 mm Hg | 02-06-26 06:46:02 |
| CA++(7.4) | 1.18 mmol/L | 02-06-26 06:46:02 |
| Lac | 0.7 mmol/L | 02-06-26 06:46:02 |
| NA+ | 132 mmol/L | 02-06-26 06:46:02 |
| Lac | 4.3 mmol/L | 04-05-26 18:19:01 |
| CA++(7.4) | 1.17 mmol/L | 24-05-26 16:01:01 |
| PO2 | 145 mm Hg | 24-05-26 16:01:01 |
| Lac | 1.0 mmol/L | 25-05-26 11:14:02 |
| NA+ | 131 mmol/L | 25-05-26 11:14:02 |
| PO2 | 136 mm Hg | 25-05-26 11:14:02 |
| CA++(7.4) | 1.19 mmol/L | 25-05-26 11:14:02 |
| NA+ | 128 mmol/L | 30-05-26 14:51:02 |
| Hepatitis B Surface Antigen (HBsAg) | Negative (0.08) | 04-05-26 19:53:01 |
| Hepatitis C Antibody (Anti HCV) | Non-Reactive (0.06) | 04-05-26 19:53:01 |
- Multislice CT scan brain plain study (04.05.2026): Tiny hemorrhagic contusion in left basifrontal region Fracures as described.
- Multislice CT scan chest plain study (04.05.2026):
- Bilateral pneumothorax and minimal right hemothorax
- Pneumomediastinum and subcutaneous emphysema as described.
- Lung contusion and laceration injury in left lung as described.
- Multislice CT abdomen and pelvis report (04.05.2026):
- No evidence of intra-abdominal injury.
- MRI of brain plain MRA with whole spine screening (06.05.2026):
- Fracture right maxillary sinus with haemosinus.
- Thin SDH bilateral posterior parietal regions.
- Multifocal tiny haemorrhagic contusions bilateral cerebral hemispheres with grade III diffuse axonal injury.
- Multislice CT scan brain (11.05.2026)
- Resolving hemorrhagic contusion in left basifrontal region
- Displaced fracture in right orbit and right maxillary sinus
- Multislice CT scan chest (11.05.2026)
- Patchy peribronchial and peripheral ground glass opacities in both lungs with mild septal thickening in upper lobes → likely pulmonary edema
Patchy peribronchial and peripheral consolidation in dependant segments of bilateral lower lobes→ Could represents aspiration pneumonitis
Mild right pneumothorax and bilateral ICD tubes
Minimal hemothorax on both sides compared to previous CT scan dated 04.05.2026 significant reduction of pneumothorax seen with interval changes as described.
Diagnosis
- RTA with severe head injury
- Grade III diffuse axonal injury
- Right 9th and 10th rib fracture with bilateral pneumothorax / right minimal hemothorax / left lower lobe consolidation – status post bilateral ICD
- ARDS
Management
On arrival his GCS was E1 VT M1, and his SpO₂ was 67% while on mechanical ventilation. The patient had been intubated with a 7.0 mm Endotracheal Tube (ETT) at the outside hospital. In view of the inadequate oxygenation, the ETT was replaced with an 8.0 mm ETT in the Emergency Room (ER). Despite this, his SpO₂ remained between 77% and 82%.
CT chest revealed bilateral pneumothorax, minimal right-sided hemothorax, pneumomediastinum, and subcutaneous emphysema. It also showed lung contusion and laceration of the left lung.
In view of the bilateral pneumothorax and respiratory compromise, bilateral intercostal chest drains (ICDs) were inserted on an emergency basis in the ER.
In view of prolonged mechanical ventilation, tracheostomy was planned, and the procedure was explained to the patient’s attendants. However, the patient developed desaturation, and hence the procedure was deferred. On 06.05.2026, the patient developed desaturation, for which bronchoscopy was performed. The procedure was uneventful, and the endotracheal tube was changed. ARDS was suspected, and the patient was managed accordingly. The patient developed fever spikes, for which appropriate antibiotics were administered. He also developed hypotension and was managed with intravenous fluids and single-inotrope support. Cardiology review was obtained for hypotension and shock, and the advised management was carried out. He was treated with IV fluids, appropriate broad-spectrum antibiotics, antiepileptic medications, analgesics, proton-pump inhibitors, antiemetics, inotropic support, nebulisation, and other supportive measures.
The patient continued to have intermittent fever spikes, which were managed appropriately. ENT surgical opinion was obtained for right nasal and oral bleeding, and conservative management was advised. The head injury was managed conservatively. Follow-up CT brain showed resolving haemorrhagic contusion in the left basifrontal region, along with displaced fractures involving the right orbit and right maxillary sinus. The right ICD was repositioned on 11.05.2026. Repeat CT chest showed a significant reduction in the pneumothorax compared with the previous CT dated 04.05.2026, with interval improvement. Pulmonologist review was obtained, and the patient underwent bronchoscopy, following which the post-procedure period was uneventful.
After obtaining informed consent, the patient underwent tracheostomy under general anaesthesia on 12.05.2026. The procedure was uneventful. Ultrasound chest showed mild-to-moderate loculated right pleural effusion. Pulmonology review was obtained, and on 15.05.2026, pigtail catheter insertion was performed under local anaesthesia. The procedure was uneventful. Gradual ventilator weaning was initiated. ENT review was obtained for discharge from the tracheostomy site, and the advised management was followed.
The left ICD was removed on 22.05.2026. The patient tolerated tracheostomy ventilation on pressure support mode, and the right ICD was subsequently removed. Tracheal culture and sensitivity grew MDR Acinetobacter and MSSA, for which appropriate antibiotics were administered based on the culture and sensitivity report. Psychiatry opinion was obtained for restlessness, and appropriate management was carried out. Orthopaedic opinion was obtained for right 9th and 10th rib fractures, and the advised management was followed.
Outcome
The patient showed clinical improvement and was shifted to the ward for further management. He tolerated tracheostomy with BiPAP followed by oxygen support. ENT review was obtained for decannulation. On 08.06.2026, a corking trial was initiated, however, the patient did not tolerate the trial, and the tracheostomy tube was reinserted. Endoscopic coblation-assisted balloon dilatation was planned. Subsequently, the patient tolerated Tracheolife in room air, and an oral feeding trial was initiated and tolerated well.
The patient underwent coblation-assisted balloon dilatation under general anaesthesia on 10.06.2026. The procedure was uneventful, and relevant specialist reviews were obtained. A repeat corking trial was initiated, which the patient tolerated for approximately 10 minutes; however, desaturation and breathing difficulty were noted and settled after uncorking. The inner cannula was not changed due to increased coughing. ENT review was obtained, and retrograde scopy was advised after neurological clearance.
Decannulation was successfully performed on 24.06.2026, which the patient tolerated well. Following decannulation, he tolerated oral feeds. The patient showed significant clinical and symptomatic improvement and was therefore discharged in a stable condition with appropriate medications, follow-up advice, and necessary instructions.
Nursing Management
- Neurological monitoring – Assessed GCS, pupil reaction, limb movement, and neurological changes regularly.
- Airway and breathing – Maintained airway patency and closely monitored SpO₂, respiratory rate, breath sounds, and respiratory effort.
- Mechanical ventilation – Monitored ventilator settings, patient-ventilator synchrony, and response to oxygen therapy.
- ICD care – Monitored bilateral chest drains for patency, drainage, air leak, and signs of recurrent pneumothorax.
- Tracheostomy care – Maintained tube patency, performed suctioning as required, provided stoma care, and monitored for infection or obstruction.
- Infection prevention – Followed strict aseptic technique and monitored for fever and other signs of infection.
- Medication management – Administered prescribed antibiotics, antiepileptics, analgesics, and other supportive medications safely.
- Haemodynamic monitoring – Monitored BP, HR, temperature, urine output, and fluid balance, especially during hypotension.
- Weaning and decannulation – Closely monitored the patient during ventilator weaning, BiPAP/O₂ support, corking trials, and after decannulation.
- Nutrition and aspiration prevention – Assessed swallowing, and maintained aspiration precautions.
- Seizure and safety precautions – Maintain seizure precautions and prevent falls and other complications.
Discharge medications
| S.no | Drug name | Strength | Frequency | Relationship With meal Days | ||||
|---|---|---|---|---|---|---|---|---|
| M | A | N | ||||||
| 1 | Tab. Levipil | 500 mg | 1 | 0 | 1 | Oral | After food | 2 weeks |
| 2 | Tab. Pantocid | 40 mg | 1 | 0 | 0 | Oral | Before food | 7 days |
| 3 | Sachet Glutaverge | - | 1 | 0 | 1 | Oral | After food | 7 days |
| 4 | Tab. Strocit Plus | - | 1 | 0 | 0 | Oral | After food | 2 weeks |
| 5 | Tab. Predmet | 8 mg | 1 | 0 | 0 | Oral | After food | 7 days |
| 6 | T Bact ointment | - | 1 | 0 | 1 | Local Application | - | 10 days |
| 7 | Neb. Ciplox D | - | 1 | 0 | 1 | - | - | 15 days |
Discussion
This case highlights the importance of early treatment and continuous monitoring in a patient with severe head and chest injuries following a road traffic accident. The patient required mechanical ventilation, bilateral ICD insertion, bronchoscopy, tracheostomy, antibiotics, and prolonged respiratory support. During the hospital stay, complications such as pleural effusion, respiratory infection, and airway problems were managed appropriately. Gradual ventilator weaning, tracheostomy care, airway dilatation, and corking trials helped the patient progress towards decannulation. Good nursing care, regular monitoring, infection prevention, and multidisciplinary management contributed to the patient’s recovery and successful discharge.
Conclusion
This case demonstrates that early intervention, continuous monitoring, effective airway and respiratory management, and multidisciplinary care are essential in patients with severe head and chest injuries following road traffic accidents. Proper nursing care, infection prevention, ventilator weaning, tracheostomy management, and timely treatment of complications contributed to the patient’s gradual recovery, successful decannulation, and safe discharge.
