Case conference Int. 林鼎博

EMT data EMT 抵達時間： 8/15 22:20 EMT 抵達時間： 8/15 22:20 Trauma accident （騎摩托車，遭廂型車撞擊後被壓在車 底） Trauma accident （騎摩托車，遭廂型車撞擊後被壓在車 底） A ：尚可說話，以頸圈固定 A ：尚可說話，以頸圈固定 B ： dyspnea ， RR = 24 B ： dyspnea ， RR = 24 C ： HR = 144 ， BP = 77 / 58 C ： HR = 144 ， BP = 77 / 58 D ： GCS = E4V5M6 D ： GCS = E4V5M6 E ：頭部撕裂傷，雙大腿反曲於胸腹上，右大腿撕裂傷， 左大腿燙傷 E ：頭部撕裂傷，雙大腿反曲於胸腹上，右大腿撕裂傷， 左大腿燙傷 Mask 10L/min Mask 10L/min 頸圈，夾板固定，長背板固定，止血 頸圈，夾板固定，長背板固定，止血

Arrival data 抵達時間： 8/15 22:43 抵達時間： 8/15 22:43 A ：呼吸平順，言語正常，需頸椎保護 A ：呼吸平順，言語正常，需頸椎保護 B ： RR > 24 / min B ： RR > 24 / min C ： HR = 74 ， BP =84 / 55 ，末梢循環正常 C ： HR = 74 ， BP =84 / 55 ，末梢循環正常 Skin ：冷，紅潤，溼度正常 Skin ：冷，紅潤，溼度正常 D ： G4V5M6 ， pupil = 3.0 ， 3.0 reactive D ： G4V5M6 ， pupil = 3.0 ， 3.0 reactive E ： Head  laceration * 1.5cm 、 avulsion E ： Head  laceration * 1.5cm 、 avulsion Chest  contusion Chest  contusion Left forearm  laceration * 5cm Left forearm  laceration * 5cm Right thigh  avulsion Right thigh  avulsion Left thigh  burn ( 2 o ， 2%) Left thigh  burn ( 2 o ， 2%) multiple abrasion multiple abrasion

AMPLE All denied All denied Last meal ： 6:00pm Last meal ： 6:00pm

Initial assessment (1) 22:56 A ： keep collar ， C-spine X-ray A ： keep collar ， C-spine X-ray B ： Chest PA ， B ： Chest PA ， C ： N/S 1 BT ， L/R 1BT C ： N/S 1 BT ， L/R 1BT D ： Brain CT + C-spine CT D ： Brain CT + C-spine CT E ： Tetanus Toxoid E ： Tetanus Toxoid Pelvis X-ray Pelvis X-ray Right knee X-ray (AP+lat) Right knee X-ray (AP+lat) CBC CBC GOT/GPT ， BUN ， Cr ， Sugar ， Na ， K GOT/GPT ， BUN ， Cr ， Sugar ， Na ， K PT / PTT PT / PTT

WBC11.16 RBC4.57 Hgb14.1 Hct44.1 MCV96.5 MCH30.9 MCHC32 PLT220 RDW-CV12.1 RDW-SD42.7 Sugar 17 7 Urea N Creatinine Na 14 2 K GOT 12 8 GPT90 PT P PT C PT(INR) PTT P PTT C 29. 1

23:05 N/S 1 BT N/S 1 BT Fentanyl 0.1mg Fentanyl 0.1mg Penicillin test Penicillin test Penicillin G 3Mu Penicillin G 3Mu

23:07 備 PRBC 4U 備 PRBC 4U Gelofusine 4% 1 BT Gelofusine 4% 1 BT Troponin I, CPK, CK-MB Troponin I, CPK, CK-MB ABO blood typing ABO blood typing Rh blood typing Rh blood typing Antibody screening Antibody screening Ethanol Ethanol

CPK 39 2 Tropo-I CK-MB 12 3 Ethanol2.2

23:10 BP = 99/64, PR = 127 BP = 99/64, PR = 127

23:15 Whole body CT (non enhanced) -- hold Whole body CT (non enhanced) -- hold

23:21 Wound treatment Wound treatment FAST ： FAST ： –No pleural or pericardial effusion is found –Intraperitoneal cavity ： nil –Lung slicing ： present –Initial FAST survey ： np Blood gas Blood gas EKG monitor EKG monitor Lactate Lactate

pH pCO pO HCO Total CO Base excess SBC BEecf-7 %sO2c Lactate5.3

23:30 N/S 1 BT N/S 1 BT L/R 1 BT L/R 1 BT

23:40 BP = 115/56 ， PR = 162 BP = 115/56 ， PR = 162 SpO 2 = 75% SpO 2 = 75%

23:50 On chest tube (32# ， fix 12cm) On chest tube (32# ， fix 12cm) Consult 骨科 Consult 骨科 –Right pubicsuperior and inferior ramus fracture –Right acetabulum posterior coloum fracture –Left femur neck fracture –Plan ： right leg skeletal traction, left leg skin traction after condition stable Consult 泌尿科 Consult 泌尿科 –Please consult again to survey GU trauma if condition is more stable 開始輸 PRBC 2U 開始輸 PRBC 2U

23:51 BP = 90/51 ， PR = 163 BP = 90/51 ， PR = 163 SpO2 = 74% SpO2 = 74% Conscious clear Conscious clear

00:05 BP = 79 / 54 ， PR = 84 BP = 79 / 54 ， PR = 84 SpO2 = 58% SpO2 = 58% Citosol Citosol On endo (7.5# ， fix 21cm) On endo (7.5# ， fix 21cm) 再接 PRBC 2U 再接 PRBC 2U

00:15 PR 量不到 PR 量不到 CPR start CPR start 0016  NaHCO 3 4 amp 0016  NaHCO 3 4 amp 0017  Adrenaline 1 amp 0017  Adrenaline 1 amp 0020  Adrenaline 1 amp 0020  Adrenaline 1 amp 0023  Adrenaline 1 amp 0023  Adrenaline 1 amp 0025  HR =90 ， BP = 98/  HR =90 ， BP = 98/70 CPR stop CPR stop

00:25 N/S 1 BT N/S 1 BT On CVP with N/S 1 BT On CVP with N/S 1 BT 接 ventilator 接 ventilator ( TV = 600ml, Rate = 20, FiO 2 = 100%) ( TV = 600ml, Rate = 20, FiO 2 = 100%)

00:  BP = 107/81 ， PR =  BP = 107/81 ， PR = 65 CVP level = 9 cmH 2 O CVP level = 9 cmH 2 O Endo 改 23cm Endo 改 23cm

00:45 Recheck CxR Recheck CxR

00:  BP = 101/82 ， PR=  BP = 101/82 ， PR=59 PRBC 2U 輸畢 PRBC 2U 輸畢 0055  BP = 96/76 ， PR =  BP = 96/76 ， PR = 69 SpO2 = 75% SpO2 = 75% N/S 1 BT N/S 1 BT

01:00 BP 量不到， HR = 39 BP 量不到， HR = 39 CPR start CPR start Adrenaline 1 amp Adrenaline 1 amp 0105  on 2nd chest tube at right side 0105  on 2nd chest tube at right side Emergent thoracotomy Emergent thoracotomy (ED thoracotomy with Clamshell incision) (ED thoracotomy with Clamshell incision) Adrenaline 1 amp Adrenaline 1 amp 0108  Adrenaline 1 amp 0108  Adrenaline 1 amp L/R 1 BT L/R 1 BT 0111  Adrenaline 1 amp 0111  Adrenaline 1 amp N/S 1 BT N/S 1 BT

01:  Adrenaline 1 amp 0114  Adrenaline 1 amp whole blood 2U whole blood 2U 0117  Adrenaline 1 amp 0117  Adrenaline 1 amp 0120  Adrenaline 1 amp 0120  Adrenaline 1 amp 0123  whole blood 2U 0123  whole blood 2U 0126  Adrenaline 1 amp 0126  Adrenaline 1 amp 0127  NaHCO 3 4 amp 0127  NaHCO 3 4 amp 0135  Gelofusine 1 BT 0135  Gelofusine 1 BT BP 79/49 ， PR = 142 BP 79/49 ， PR = 142 CPR stop CPR stop

01:45 BP = 50/30 ， PR = 150 BP = 50/30 ， PR = 150 Dopamine Dopamine Unasyn Unasyn Sent patient to OR Sent patient to OR

In OR room 01:45 Clamshell incision was made for rapid access and bleeding control. Clamshell incision was made for rapid access and bleeding control. Manual cardiac massage was performed after the pericardiotomy was made. No pericardial effusion was noted. Manual cardiac massage was performed after the pericardiotomy was made. No pericardial effusion was noted. Active bleeding via huge laceration is found over RLL. Active bleeding via huge laceration is found over RLL. Primary repair is performed via continuous suture. Primary repair is performed via continuous suture. Dull response to our effort gradually developed!! Dull response to our effort gradually developed!! Heart asystole Heart asystole 急救無效， 04:00 離開 OR ，送回 ER 急救無效， 04:00 離開 OR ，送回 ER

輸液整理 + 大事紀 N/S ： 2256, 2305, 2330, 0025*2, 0055, 0111 ( 共 3500cc) N/S ： 2256, 2305, 2330, 0025*2, 0055, 0111 ( 共 3500cc) L/R ： 2256, 2330, 0118 ( 共 1500cc) L/R ： 2256, 2330, 0118 ( 共 1500cc) Gelo: 2307, 0135( 共 1000cc) Gelo: 2307, 0135( 共 1000cc) PRBC = 2350* *2 ( 共 1000cc) PRBC = 2350* *2 ( 共 1000cc) Whole= 0114*2+0123*2( 共 1000cc) Whole= 0114*2+0123*2( 共 1000cc) 總輸液量 = 8000 – 1850 = 6150cc 總輸液量 = 8000 – 1850 = 6150cc 2243  arrival 2243  arrival 2340  SpO2 = 75% 2340  SpO2 = 75% 2350  1st chest tube 2350  1st chest tube 0005  SpO2 = 58% ， on endo 0005  SpO2 = 58% ， on endo 0015  PR 量不到， 1st CPR 0015  PR 量不到， 1st CPR 0100  BP 量不到， PR=39 ， SpO2 = 75% 0100  BP 量不到， PR=39 ， SpO2 = 75% 2nd CPR ， 2nd chest tube ， ED thoracotomy 2nd CPR ， 2nd chest tube ， ED thoracotomy

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