2007-7-17外傷科 Intern 趙家宏

Trauma Case Conference

Patient Profile 馬王○雪， 28y/o ， Female Date of ER visiting ： 2007-07-09 Mechanism of Injury ：計程車副駕駛乘客，卡

在椅子和手套之間 Sent to our ER at 05:44 AM by EMT

Condition at Scene Vital sign: BP 105/59, T/P/R:36.9/111/10 AVPU ： Unrespondsive, GCS scale: Ｅ 1V1M5, Consciousness:

coma On neck collar

Resuscitation Start resuscitation on 5:44 AM

On E-T tube Fr-7.5, fixed 22 cm IVF: L/R 1000 cc, N/S:1000cc On Monitor On neck collar

Primary Survey and Management

Airway On oral endotracheal tube Assume a cervical spine injury and on neck collar

Breathing Artificial ventilation Decompression and drainage of tension

pneumothorax/haemothorax

Primary Survey and Management

Circulation with haemorrhage control Stop external haemorrhage Establish 2 large-bore IV lines (14 or 16 G) if

possible with administer fluids Disability

A V P U: unresponsive Exposure

Left knee laceration wound 5-6 cm

Primary Survey and Management

Lab CBC, DC, CRP GOT,GTP, Bun, Cr, Na, K PT,PTT Troponin-I, CPK, CK-MB

X-ray CXR Pelvic

CT Brain

Wound CD and suture laceration wound with nylon 4-0

2007/7/9 6:00 AM

2007/07/09 6:00 Brain CT

Brain CT finding

Traumatic subarachnoid hemorrhage with rupture into ventricles.

Suspect subdural hemorrhage along the anterior falx.

Right pneumothorax with left hemothorax On endotracheal tube. No imaging evidence of C-spine fracture.

Lab

Secondary Survey and Management

Airway On oral endotracheal tube On neck collar

Breathing R’t pneumothorax and left hemothorax Artificial ventilation On chest tube (6:25 AM)

Secondary Survey and Management

Circulation with haemorrhage control PRBC 2u at 9:00AM

Disability and Differential Diagnosis SAH and SDH consult NS Elevated liver enzyme: liver laceration is

suspected Arrange abdominal CT Exposure

Left knee laceration wound with suture line

Chest X-ray 7:30chest tube 太深，外拉 2cm

Abdomen CT <8:00 AM>

Abdominal CT finding

Liver laceration injury of S8 of r’t hepatic lobe , with hemoperitoneum, AAST:Gr III-IV, cannot rule out active bleeding

Hemopericardium Bil hemothorax

Impression

Traumatic SAH and IVH R’t pneumothorax left hemothorax Liver laceration Gr III-IV Hemopericardium r/o cardiac temponade

Resuscitation 10:00 AM

Give hyperventilation, FiO2 set 30% 輸血 PRBC 2U(9:00), 備血 PRBC 6U

10:20 AM BP 86/45 PR 120/min Keep blood transfusion PE: BS, bil present, coarse over l’t side, mild

decrease over r’t side, Abdomen: soft Consult HBS surgeon Consult CVS

HBS surgery 7/9

1. Dx:Liver laceration

2. Laparotomy+hepatorrhaphy+choleycystostomy+ packing of liver

7/13

1. Liver packing gauze remove

CVS surgery

7/9r/o hemopericardium , Ant mediestinum hematoma

1. Explore pericardiotomy <No hemopericardium, ,inimal pericardial effusion>

2. Fr 28 chest inserted to the substernal space 7/10 r/oAnt mediestinum hematoma,

manubrium fracture1. Sternum ORIF, check bleeding