Case Conference- 急診外科 Presenter: Int. 黃士財 Director: 林杏麟醫師 Date: 2006-09-05.

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Presentation transcript:

Case Conference- 急診外科 Presenter: Int. 黃士財 Director: 林杏麟醫師 Date:

Patient profile:  Name: 許╳恩  Gender: male  Age: 10 years old  ID:  Time: , 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 /75 E1V1M1 否 /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  SpO 2 : 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 oximetry,  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, GOT/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 data 9/028:37PM Temp37.2 PH7.303 PCO245.5 PO HCO3-22 BE-4.5 SBC20.6 Becf-4.4 %O /2 (6:25pm) 9/4 WBC RBC HgB HCT40.6%36.4 MCV MCH MCHC PLT RDW-CV RDW-SD /029:00PM PTp/PTc13.4/10.8 PT(INR)1.35 PTTp/PTTc31.9/28.2 Sugar221mg/dl BUN/Cr58/0.69 Na/K141/3.21 GOT/GPT82/44 CPK579 CK-MB219.7 Tropo-I0.018

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,right 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 hemopneumothorax /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