Case Presentation Intern 蔡孟峰. Chief Complaint Traffic accident last midnight(06/03), transferred from “ 劉光雄 ” Hospital

Case PresentationCase Presentation

Intern Intern 蔡孟峰蔡孟峰

Chief ComplaintChief Complaint

Traffic accident last midnight(06/03), trTraffic accident last midnight(06/03), transferred from “ansferred from “ 劉光雄” 劉光雄” HospitalHospital

Present IllnessPresent Illness

The 21-year-old male is well-being before.The 21-year-old male is well-being before.

Last night, he went out with his friends, sittinLast night, he went out with his friends, sitting in the middle of the backseat. g in the middle of the backseat. Around 22:00, the car crashed a wire pole.Around 22:00, the car crashed a wire pole.

He didn’t know anything until he woke up in He didn’t know anything until he woke up in ““ 劉光雄” 劉光雄” hospital. Several management whospital. Several management were done there. ere done there.

Present IllnessPresent Illness

Diagnosis at Diagnosis at 劉光雄劉光雄 hospitalhospitalConsciousness drowsyConsciousness drowsy

Head injury with brain swellingHead injury with brain swelling

Right thigh painful deformityRight thigh painful deformity

Right femur fractureRight femur fracture

Right leg Right leg 固定在護木位置固定在護木位置Then, he was transferred to our ER for furthThen, he was transferred to our ER for further management.er management.

The Status on ArrivalThe Status on Arrival

Consciousness : alert, E4V5M6Consciousness : alert, E4V5M6

Respiratory Rate : 10 ~ 24 / minRespiratory Rate : 10 ~ 24 / min

Pulse Rate : 127 /minPulse Rate : 127 /min

Blood Pressure : 163 / 93 mmHgBlood Pressure : 163 / 93 mmHg

Body Temperature : 36.8 Body Temperature : 36.8 ooCC

At ER, right femoral fracture and At ER, right femoral fracture and

dyspnea were told. dyspnea were told.

Initial AssessmentInitial AssessmentA : patent airwayA : patent airway

B : spontaneous breathingB : spontaneous breathing

C : radial pulse (+)C : radial pulse (+)Pulse rate : 127/minPulse rate : 127/min

Blood pressure : 163/93 mmHgBlood pressure : 163/93 mmHg

D : E4V5M6D : E4V5M6

E : trauma at E : trauma at Left lower pulmonary areaLeft lower pulmonary area

Epigastric areaEpigastric area

Right upper femoral areaRight upper femoral area

Focused historyFocused history

AAllergic : deniedllergic : denied

MMedication : deniededication : denied

PPast medical history : deniedast medical history : denied

LLast meal : unknownast meal : unknown

EEvents: traffic accidentvents: traffic accident

PlanPlan

CBCCBCGOT/ GPT/ BUN/ Creatinine/ GOT/ GPT/ BUN/ Creatinine/ Sugar/ Na/ KSugar/ Na/ KPT/ APTTPT/ APTTEthanolEthanolCross matching/ PRBC 2UCross matching/ PRBC 2ULactated Ringer IVD : 500c.c.Lactated Ringer IVD : 500c.c.NPONPONasal CannulaNasal Cannula12 lead EKG12 lead EKG頸圈固定頸圈固定

X-rayX-raySkull AP, LateralSkull AP, LateralChest APChest APSpine AP, Lateral, NeckSpine AP, Lateral, NeckFemurFemurPelvisPelvis

CT scan : abdomenCT scan : abdomen適應症適應症 : R/O internal : R/O internal bleeding bleeding

Available Lab DataAvailable Lab Data

WBC(10WBC(1033/μl) /μl) 18.2818.28

RBC(10RBC(1088/μl)/μl) 5.225.22

Hgb (g/dl)Hgb (g/dl) 10.610.6

Hct (%)Hct (%) 34.934.9

MCV ( fl )MCV ( fl ) 66.966.9

MCH (pg)MCH (pg) 20.320.3

MCHC (g/dl)MCHC (g/dl) 30.430.4

PLT (10PLT (1033/μl)/μl) 151151

Neut (%)Neut (%) 88.988.9

Eosin (%)Eosin (%) 0.10.1

Baso (%)Baso (%) 0.10.1

Lymph Lymph (%)(%)

7.27.2

Mono (%)Mono (%) 3.73.7

Available Lab DataAvailable Lab Data

GOT (μ/L)GOT (μ/L) 7676

GPT (μ/L)GPT (μ/L) 5959

BUN (μ/L)BUN (μ/L) 11.911.9

CREA ( mg/dl)CREA ( mg/dl) 0.910.91

Na (Meq/L)Na (Meq/L) 139139

K (Meq/L)K (Meq/L) 3.783.78

Cl(Meq/L)Cl(Meq/L) 114114

Sugar (mg/dl)Sugar (mg/dl) 193193

Ethanol Ethanol (mg/dl)(mg/dl)

<5.0<5.0

PT (p)PT (p) 14.214.2

PT (c)PT (c) 10.510.5

INRINR 1.501.50

PTT(p)PTT(p) 32.132.1

PTT(c)PTT(c) 29.729.7

ManagementManagement

01 : 0001 : 00Gelofusine 500 c.c. IVGelofusine 500 c.c. IV

PRBC 2U stPRBC 2U st

01 : 1001 : 10SpOSpO22= = 89%89%

OO2 2 : 3 l/min : 3 l/min

01 : 1501 : 15BP : BP : 138/66138/66 mmHg, pulse : mmHg, pulse : 136136 /min /min

開始輸開始輸 PRBCPRBC


01 : 2501 : 25BP : BP : 123/53123/53 mmHg, pulse : mmHg, pulse : 137137 /min, SpO /min, SpO22 : : 100%100%

X-ray surveyX-ray survey

01 : 30 01 : 30 CT-scan (abdomen)CT-scan (abdomen)

適應症適應症 : R/O internal bleeding : R/O internal bleeding

?? FAST scan ?? FAST scan Fluid accumulation over Fluid accumulation over Morison’s pouchMorison’s pouch

ImageImage

劉光雄醫院

Abdominal CTAbdominal CT















ReportReportSplenic laceration with hemoperitonum.Splenic laceration with hemoperitonum.

Left pneumothorax.Left pneumothorax.

Contusion hemorrhage at both pulmonary Contusion hemorrhage at both pulmonary lower lobes.lower lobes.

Pelvic fracture at bilateral superior rami of Pelvic fracture at bilateral superior rami of pubis, right ilium and right aspect of sacrupubis, right ilium and right aspect of sacrum.m.

Soft tissue swelling over left lower flank.Soft tissue swelling over left lower flank.


01 : 5501 : 55O : internal bleedingO : internal bleedingon Foley on Foley

02 : 0002 : 00BP :BP :120/54120/54 mmHg, HR : mmHg, HR : 123123 /min, SpO /min, SpO22 : : 100%100%

BP :BP :123/49123/49 mmHg, HR : mmHg, HR : 144144 /min, SpO /min, SpO22 : : 98%98%

L/R 500 c.c. IV stL/R 500 c.c. IV stBT PRBC 2UBT PRBC 2U FFP 6U FFP 6UTransamin 2Amp IVTransamin 2Amp IVVit C / Amp IVVit C / Amp IV

Hematuria


02 : 2002 : 20BP : BP : 100/40100/40 mmHg, HR : mmHg, HR : 170170 /min /min

R/O internal bleeding, hematuriaR/O internal bleeding, hematuria

Admission to GSAdmission to GS

Cefazolin 1g vial IVCefazolin 1g vial IV

Gentamicin 80mg/ Amp IMGentamicin 80mg/ Amp IM

7ESI-27ESI-2

On CVPOn CVP

顏面縫合顏面縫合 Nylon 6-0Nylon 6-0


02 : 3502 : 35BP : BP : 132/51132/51 mmHg, pulse : mmHg, pulse : 119119 /min /min

02 : 4502 : 45

BP : BP : 121/63121/63 mmHg, pulse : mmHg, pulse : 122122 /min, BT : /min, BT : 35.635.6 ooCC

離開離開 ERER

Diagnosis at ERDiagnosis at ER

Right femoral shaft fracture AIS=2Right femoral shaft fracture AIS=2

R/O linear laceration AIS=3R/O linear laceration AIS=3

R/O acetabular fracture, bilateralR/O acetabular fracture, bilateral

Left occult pneumothorax AIS=3Left occult pneumothorax AIS=3

R/O pubic ramus fractureR/O pubic ramus fracture

Renal contusionRenal contusion

R/O U-B ruptureR/O U-B rupture

ISS=22ISS=22

Documents

Case Presentation Intern 蔡孟峰. Chief Complaint Traffic accident last midnight(06/03), transferred from “ 劉光雄 ” Hospital