Combine Conference 外科/急診 Reporter : ED R4 黃建雄 Supervisor :李景行醫師 April 8, 2014
General data 42 y/o, male Time of arrival: 2013/12/07 20:59 Triage 檢傷一級 trauma blue 病患來診為自2樓墜樓 Vital signs T:35 P:60 R:19 SBP:89 DBP:40 E:4 V:5 M:6
Chief complaint Fell down from 3 meters (一層樓高) high
Present illness no head contusion, no ILOC back pain:+ denied chest or abdominal pain no SOB alcochol consumptiom:+
Past history DM- HTN-
Physical Examination General appearance : ill Conscious : clear Pupil size : 3+/3+ HEENT not anemic, anicteric Neck no jugular enlargement Chest: bil BS clear Heart : RHB , no murmur Abdomen soft and flat, normo-active BS Extremities: free movable, no gross deformity Back no tender Skin: no open wound
What should we do now?
ATLS Principle Primary survey A Airway and C spine Secondary survey B Breathing and ventilation C Circulation and hemorrhage D Disability and neurologic status E Exposure and Environment Secondary survey 在此SLIDE中 應一一對照出此病人的相對應問題 ( by oral presentation, discussing with audience) my opinion as following A: airway seems OK, no facial trauma, no hemoptysis / hematesis; C spine no check B: breathing, not OK, but pulse oximeter? Under room air? Suspected tension pneumothorax,? What about tracheal position? Chest percussion; if highly suspected should do the needle decompression at firstly, or portable chest X ray? C : not good, bleeder? fluid resuscitation, pt got at least class III blood loss, should replacement with blood transfusion as soon as possible D: seems OK E: checking? How about pt’s back?
Hypovolemic shock: most in trauma patient Class 1 Class 2 Class 3 Class 4 Blood loss (ml) Up to 750 750~1000 1500~2000 >2000 Blood loss (%) Up to 15% 15%~30% 30%~40% >40% Pulse rate <100 100~120 120~140 >140 Blood pressure normal decreased Pulse pressure Normal or increased Respiratory rate 14~20 20~30 30~40 >35 Urine output (ml/hr) >30 5~15 negligible CNS/mental status Slightly anxious Mildly anxious Anxious, confused Confused, lethargic Fluid replacement crystalloid Crystalloid and blood 這個TABLE 是舊版的 NEW的多一個COLUMN: initial fluid replacement
Non-hemorrhagic shock Neurologic shock --disruption of the autonomic pathways within the spinal cord --central nervous system damage (brain injury, cervical or high thoracic spinal cord) --Tx: fluid or inotropic
Non-hemorrhagic shock Obstructive --Cardiac temponade --Tension pneumothorax
Back to our patient 20:59pm (0min) CBC, WBC/DC, PT, APTT BUN/Cr, ALT, Na, K, sugar Ethyl alcohol On monitor Prepare PRBC 2U IV challenge 1000cc stat IV with N/S 1000ml run 80cc/hr
Chest PA view C-spine lateral view T-L spine lateral view CT (contrast +/-) of abdomen and chest Keto 1pc IM
Do you agree? What will you do?
On neck collar More aggressive fluid resuscitation Warm IV fluid FAST Contact Trauma doctor
Image 21:10 pm (11mins)
CT finding 1.Spleen laceration with active bleeding and hemoperitoneum 2.Left 9th-11th ribs close fracture
Imp: 1.Spleen laceration with active bleeding and hemoperitoneum 2.hypovolemic shock 3.Left 9th-11th ribs close fracture
21:22pm (23min) 開立病危通知單 : 脾臟破裂 Consult 外傷小組 Vitals after 1000 N/S challenge BP:90/44 HR:70
Can J Surg 2008;51(6):464)
Stable or Unstable TAE or Laparotomy Next step Stable or Unstable TAE or Laparotomy Contact radiologist 也可以了解prepare 需要多久時間!!
21:47pm (48min) TR-GS consult sheet completed Arrange TAE B/T with PRBC 4U stat(緊急備血) IV challenge with N/S 1000cc stat(2nd) IVF2: N/S 1000ml run 120cc/hr Admitted to Trauma ICU
Lab data WBC 10900 RBC 3.79 seg 36 Hb 13.9 lymphocyte 55 Hct 39.1 monocyte 8 MCV 103.2 eosinophil MCH 36.7 MCHC 35.5 P.T 11.6 RDW 15.1 INR 1.11 Platelet 96K APTT 26.3
Lab data BUN/Cr 7/1.31 sugar 159 ALT 60 Na 144 K 2.03 alcohol 276
22:14pm (1h 15m) Vitals: BT:36℃ pulse:81 RR:16 BP: 77/41 IVF 1 renew: N/S 1000ml + KCL 40meq run 80cc/hr KCL 1pc in N/S 100cc run 20 mins On right neck Large bore B/T with PRBC 2U and FFP 2U stat (緊急備血)
Stable or Unstable? Contact radiologist 也可以了解prepare 需要多久時間!!
22:35pm (1h 36m) TAE or Laparotomy? Vitals before TAE: BT:36 pulse:86 RR:19 BP:66/41 TAE or Laparotomy?
22:40pm(1hr 41m)送TAE 23:30pm(2hrs 31m)完成 Full text: Angiography of celiac trunk, splenic artery and transaterial embolization show: 1. Multiple small contrast extravasation in the upper pole of spleen. 2. Transarterial embolization was performed after superselectively cannulated into the superior and middle branches of splenic artery with coils. (4x2 mm-COOKx 3, 3x2mm-COOK x 1, VortX-4x4mm x 1) 3. The subsequent post-TAE angiography of the splenic artery showed successful cessation of the bleeder. 4. Patient tolerated this procedure well. IMP: Splenic laceration with contrast extravasion post TAE with coils.
Vitals during TAE BT HR RR BP 23:00 36 125 19 156/46 23:09 122 74/39 23:17 35.8 118 20 53/36 23:30 101 58/35 23:32 110 61/47
23:54pm after TAE Cons change, FS:281 Dyspnea and SOB Blood arterial gas:
00:10am (3hrs 11mins) Intubation Jusomin 4pc IV stat B/T with PRBC 4U and FFP 2U stat 00:23pm (3hrs 24m) Sudden bradycardia and then PEA CPCR sucess after bosmin 3pc IV with N/S 1000cc challenge
What should we do now? Re-evaluate!! ACLS Airway patency? Lung contusion or delayed hemothorax? Pneumothorax with tension? Circulation, other ongoing bleeding? Obstructive shock? Cons change with CO2 retention – pupils? brain CT? 口述應該re-evaluate 甚麼? Tension pneumo, endo position, BS, cardiaqc tamponade, quick bed side echo hypothermia? Un-control bleeding?
Afterward… Dopamine line (00:42am) Levophed line (1:16am) Arterial blood gas after intubation:
FAST: increasing amount of ascites Consult Trauma doctor f/u (1:40am) 2:18am B/T with FFP 2U and PLT 24U stat 2:25am: emergent laparotomy
OP record 2:52am enter OR, 3:23am time out,7:30am手術結束 Patient had persisted bradycardia and hypotnesion episode, family decide DNR and patient expired on 9:45am 12/8 in ICU
Take home message 需熟悉出血性休克的處理。除了crystalloid fluid給予，必要時須盡早給予輸血，並避免coagulopathy，尤其病患可能為alcoholism 當外傷病患由stable condition轉變為unstable condition時，需立刻重新評估並考慮改變治療方向。 根據ATLS, hemodynamic unstable patient合併hemoperitonium，需接受emergent surgical exploration。
Thank you for your attention !