Case Conference Int. 林美琪 96/04/03

Patient profile ► 李  季, 27y/o, male ► Chart num.: ► Admission to ER date: 96/03/30 04:36 ► Way of admission: 119 ► Discharge from ER date: 96/03/31 12:30

Injury mechanism ► According to the inhabitant ’ s description, a great sound “ bump ” was heard. Falling down was suspected, but there is no witness. ► 現場生命徵象 : Coma(E1V1M1)

Pre-hospital evaluation and management ► sent to KMUH ER ► Head: ILOC(+), dizziness(?), headache(?), nausea/vomiting(?), amnesia(?), vertigo(?) ► Neck: pain(?), stiff(?), soreness(?) ► Chest: pain(?), dyspnea(?) ► Abdomen: pain(?), discomfort(?) ► Limbs and skin : Bilateral forearm deformity, Bilateral forearm deformity, Right knee abrasion wound, Right knee abrasion wound, Face deep laceration wound, Face deep laceration wound, Mandible deformity Mandible deformity  頸圈, 長背板固定, 左右手木板固定, 傷口包紮, 評估意識及生命跡象 傷口包紮, 評估意識及生命跡象

Initial evaluation (KMUH) A (airway) / B (breathing): RR:20cpm, SpO 2 :70% RR:20cpm, SpO 2 :70% Collar fixation: need Collar fixation: need Airway: respiration: not smooth Airway: respiration: not smooth airway obstruction sign: airway obstruction sign: cyanotic and strider cyanotic and strider blood in the mouth blood in the mouth trachea: mid-position trachea: mid-position breathing sound: bilateral rales breathing sound: bilateral rales

C (circulation): Rate: 64 bpm Rate: 64 bpm brachial a.: normal brachial a.: normal carotid a. : normal carotid a. : normal femoral a.: normal femoral a.: normal dorsalis pedis a.: normal dorsalis pedis a.: normal Cuff BP: 123/104 mmHg Cuff BP: 123/104 mmHg Skin condition: appearance: not pale Skin condition: appearance: not pale temp: warm (36.2 ’ C) temp: warm (36.2 ’ C) humidity: normal humidity: normal Suspect: facial bone fracture and subcutaneous hematoma Suspect: facial bone fracture and subcutaneous hematoma

D (disable): GCS: E1V1M1 GCS: E1V1M1 Pupil : Pupil : od: 1mm, (-/-) os: 4mm, (-/-)

E (exposure): L ’ t face deep laceration (7cm) L ’ t face deep laceration (7cm) L ’ t and R ’ t forearm deformity L ’ t and R ’ t forearm deformity R ’ t knee abrasions wound R ’ t knee abrasions wound No bruise over bilateral buttock and hip area No bruise over bilateral buttock and hip area No urethra meatus bloody discharge No urethra meatus bloody discharge

Initial Resuscitation ► On endotracheal tube (#7.5, fix 22cm) and assist ventilation  RR:24/min, TV:700ml, FiO 2 :40% ► Maintain cardiac monitor ► Insert 2 large-born IV line and rapid infusion of crystalloid solution (N/S and L/R) ► On CVC ► On foley and OG ► Collect blood sample and urine routine for initial laboratory studies

Initial Radiographic Studies ► Brain CT (without contrast) Brain CT Brain CT  subarachnoid hemorrhage in left Sylvian fissure, left fronto-parietal regions and basal cistern  brain edema  skull base fracture  bilateral maxillary and mandible fracture  hemosinus in all paranasal sinuses ► FAST : no intra-abdominal free fluid accumulation

► Left forearm AP and Lat X-ray Left forearm Left forearm  left distal radial and ulnar fracture, closed ► Right forearm AP and Lat X-ray Right forearm Right forearm ► Right knee AP and Lat X-ray Right knee Right knee ► Right elbow AP and Lat X-ray Right elbow Right elbow  right humeral fracture, closed ► Chest X-ray Chest X-ray Chest X-ray

► 12-Lead EKG ► C-spine CT C-spine CT C-spine CT  Subarachnoid hemorrhage in the basal cistern and extending into cervical thecal sac.  Fractures of left posterior tubercle & left inferior articular facet of C6, left posterior tubercle of C7, left transverse process of T1, T2, and left 1st, 2nd ribs. ► Pelvis CT Pelvis CT Pelvis CT  No image evidence of pelvic fracture

Past history ► IV drug abuser (heroin addiction) ► DM (-) ► HTN (-) ► Hepatitis B or C carrier: denied ► Op. hx.: denied ► Allergy hx.: denied ► Family hx.: non-contributory

Lab data

Tentative diagnosis ► head injury /c skull base fracture /c traumatic SAH ► bilateral maxillary and mandible fracture ► right humeral fracture, closed ► left distal radial and ulnar fracture, closed

Ongoing Evaluation & Resuscitation ► Monitor vital sign and conscious level ► Evaluate the evidence of new or ongoing signs of shock ► Antibiotics usage: cefazolin + GM ► Keep patients warm ► Consult NS: admitted to NS ICU for further care ► Consult OW: casting the elbow and forearm fracture

After admission ► 03/31 PM4:35: BP drop and pulseless  Bosmin 1 Amp iv.  Dopamin 4 Amp + N/S 500ml Keep 30 ml/hr  Sigh DNR, then AAD

Thanks for your attention!!

mandible fracture maxillaryracture maxillary fracture hemosinus

sphenoid bone (skull base) fracture Subarachnoid hemorrhage Brain edema