Case Conference- 急診外科

Presenter: Int. 黃士財Director: 林杏麟醫師

Date: 2006-09-05

Patient profile:

Name: 許╳恩 Gender: male Age: 10 years old ID: 23088220 Time: 2006-09-02, around 6:00pm

Pre-hospital Assessment Incident: crushed by a sport utility vehicle near

龍華國中 Brought by an 119 ambulance with neck collar,

Spinal Broad, and Simple mask (O2: 10L/min) 否 24 130 155/75 E1V1M1

否 20 134 157/72 E1V1M1 抵院時基本狀態：

Respond to pain, RR: 10~24/min, BP: 152/110 mmHg, Pulse: 149 bpm, BT: 37.2’C ， GCS score: E1V1M1

Primary ABCD

Airway

Neck collar Airway obstruction sign: Cyanotic,

Breathing Respiration rate:18/min

→On simple mask, O2 : 6L/min

No trachea deviation Breathing sound: bilateral rale and rhonchi Subcutaneous cripitus: right side

Echo finding: no lung sliding, 霧霧的→ Right thoracostomy was performed at 6:25pm

SpO2: 94%

Circulation Check four limbs pulse:

BP: 左手： BP: 130/80mmHg, pulse: 142/min 右手： BP:146/72mmHg, pulse: 134/min 右腳： BP: 骨折無法測量 , pulse: OK

Peripheral circulation: Skin color: red Temperature: warm Capillary refilling time: not performed

Bleeding: 懷疑胸腔內持續出血 FAST: Morrison’s pouch, Splenic fossa, cul-de-sac,

pericardium, no fluid acclumination.

Disability and Exposure

GCS score: E2V2M4, 總分： 8 Pupil: sluggish, right 5mm/5mm 移除衣物，在背部發現有一大片 Abrasion

wound.

Menagement Neck collar, Simple mask 6L/min, Pulse oximetr

y, EKG monitor, Peripheral line N/S 1 bot On chest tube, right and left side Lab exam: CBC, PT/PTT, Sugar, BUN/Cr, Na/K, G

OT/GPT, CPK/CKMB/Tropo-I Image:

X-ray: Chest ,Elbow (R), Humor (L), Low leg (R), Femur (R), Pelvis

CT: C-spine, Head (with and without contrast), chest, abdomen

Lab data9/02 8:37PM

Temp 37.2

PH 7.303

PCO2 45.5

PO2 109.4

HCO3- 22

BE -4.5

SBC 20.6

Becf -4.4

%O2 97.5

9/2(6:25pm)

9/4

WBC 15.94 11.05

RBC 5.01 4.41

HgB 13.2 12

HCT 40.6% 36.4

MCV 81.8 82.5

MCH 26.3 26.8

MCHC 32.5 32.4

PLT 329 169

RDW-CV 13.6 14.4

RDW-SD 40.5 43.9

9/02 9:00PM

PTp/PTc 13.4/10.8

PT(INR) 1.35

PTTp/PTTc 31.9/28.2

Sugar 221mg/dl

BUN/Cr 58/0.69

Na/K 141/3.21

GOT/GPT 82/44

CPK 579

CK-MB 219.7

Tropo-I 0.018

Image Finding

Image finding CT of Chest:

1. Bilateral pneumothorax and suspicious bilateral hemothorax s/p right chest tube insertion with subcutaneus emphysema at right lateral chest wall.

2. Deformity of left 5th, 6th, 7th, 8th and 9th ribs, suspect old fracture.

CT of head:1. Subgaleal hematoma at left temporo-parietal scalp. 2. Left maxillary hemosinus; sphenoid, right frontal,righ

t ethmoid and right maxillary sinusitis/hemosinuses.

19:15 BP: 142/66mmHg, PR: 134/min 19:45 BP: 141/96mmHg, PR: 142/min

conscious: clear (while performed CT) 20:10 BP: 140/70mmHg, PR: 135/min

BT: 36.6’C, sPO2: 95% Admitted to 5C at 9:15,

all purpose 35% 10L/min

急診初步診斷 Traumatic left pneumothorax and right h

emopneumothorax /c lung contusion Traumatic asphyxia Right femoral bone fracture Left upper arm crushing injury Back contusion /c abrasion Head injury /c scalp abrasion

Current condition

Remove bilateral chest tube on 9/4