Emergency department Case report Date: Intern 韓易庭

Patient profile Name: 陳雷 X Age: 19y/o Gender: male Chart number: Room number: 18ES 55 Admitted time: PM 20:39

Pre-hospital phase Transferred from 小港 hospital Event: Hit by iron rod in chest and abdomen while working Pre-hospital vital signs: unknown AMPLE: unknown Trauma evaluation: Chest and abd blunt injury Spleen laceration Left kidney laceration Left pneumothorax Left Colles ’ fracture Emergency Treatment: L/R 1500ml, N/S 100ml, Aspegic, Transamin, Demerol Chest CT, Abd CT

Status on arrival PM 20:39 Conscious: alert Respiration: 10~24 cpm Blood pressure: 119/41 mmHg Pulse rate: 99 bpm Body temperature: 36 degree 檢傷分級： 1st degree Foley:????????

Chief complaint and observation (patient and family) Dyspnea? chest tightness? Left wrist pain? Left abdominal distension? Tnederness? Discomfort?

 Primary ABCDE Open pneumothorax Tension pneumothorax Cardiac temponade Airway obstruction Flail chest Massive hemothorax Exposure Disability Circulation BreathingAirway ImmobilizationpercussionSkin colorPupil sizeEchymosisObstructionRR, BSBP, PRGCSDeformity

Primary ABCDE Airway Breathing Circulation Disability Exposure Conscious: alert Respiration: 10~24 cpm Blood pressure: 119/41 mmHg Pulse rate: 99 bpm Body temperature: 36 degree

Initial Management PM 20 ： 53 N/S 1000ml IVD EKG, SpO2 monitor Nasal cannula 4L/min CXR, KUB, Left forearm CBC, PT/PTT, Blood type cross test Consult Uro Consult GS On CVP, left subclavian Abdominal CT SpO2 99%

Image from 小港

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Image: intravenous urography (IVU)

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Abdominal CT

Lab data PM 20:53 一般血液檢驗 檢 體 :Blood 項 目 : WBC RBC HGB HCT MCV MCH MCHC 日期 ( 時間 ) x1000/ul x10^6/ul g/dl % fl Pg g/dl 檢 體 :Blood 項 目 : PLT RDW-CV RDW-SD 日期 ( 時間 ) x1000/ul % fl

Lab data PM 20:53 PT P:13.1 second PT C:10.7 second PT(INR): 1.30 R PTT P: 26.8 second PTT C: 29.5 second

Lab data PM20:53 Glu(AC): 153 mg/dl GOT: 46IU/L GPT: 34IU/L BUN(B): 15 mg/dl CRTN(B): 1.43 mg/dl CK: 256 IU/L CK-MB: 53 IU/L Amylase: 49 IU/L

Problem list Internal bleeding: spleen and L ’ t kidney laceration Pneumothorax Left Colles ’ fracture Spleen injury scale (1994 revision) Grade I Subcapsular hematoma of less than 10% of surface area Capsular tear of less than 1 cm in depth Grade II Subcapsular hematoma of 10-50% of surface area Intraparenchymal hematoma of less than 5 cm in diameter Laceration of 1-3 cm in depth and not involving trabecular vessels Grade III Subcapsular hematoma of greater than 50% of surface area or expanding and ruptured subcapsular or parenchymal hematoma Intraparenchymal hematoma of greater than 5 cm or expanding Laceration of greater than 3 cm in depth or involving trabecular vessels Grade IV Laceration involving segmental or hilar vessels with devascularization of more than 25% of the spleen Grade V Shattered spleen or hilar vascular injury Kindey injury scale (Moore 1989) Grade 1 Hematuria with normal imaging studies Contusions Nonexpanding subcapsular hematomas Grade 2 Nonexpanding perinephric hematomas confined to the retroperitoneum Superficial cortical lacerations less than 1 cm in depth without collecting system injury Grade 3 Renal lacerations greater than 1 cm in depth that do not involve the collecting system Grade 4 Renal lacerations extending through the kidney into the collecting system Injuries involving the main renal artery or vein with contained hemorrhage Segmental infarctions without associated lacerations Expanding subcapsular hematomas compressing the kidney Grade 5 Shattered or devascularized kidney Ureteropelvic avulsions Complete laceration or thrombus of the main renal artery or vein The spleen, g, is a highly vascular organ that filters an estimated 10-15% of total blood volume every minute. One kidney 150 cc, One Renal blood flow 600cc Counts for ¼ of cardica output, about 1200cc/min.

 Secondary ABCDE From Head to Toe Laceration wound Tracheal deviation Jugular venous engorgement Subcutaneous emphysema Speculation Palpation Percussion Auscultation Fracture Laceration wound Speculation Palpation Percussion Auscultation Fracture Distal palpation Sensation Range of motion Split Laceration wound Tenderness point Deformities Fracture ChestPelvic Extremities Back and hip Head and Neck

Time line  PM 21:10  PRBC 2U  Gelofusine 4% 1BT  N/S 500ml IVD  烤燈  PM 21:30  PM 22:00  On chest tube 32#  left, keep 10cm  F/U CXR BP ： 73/30 mmHg PR: 94bpm SpO2: 100% CVP level: 2cm H2O BP ： 121/61 mmHg PR: 88bpm SpO2: 100% BP ： 114/71 mmHg PR: 104bpm SpO2: 100%

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Time line PM 22:30 PRBC 2U  OP FFP 6U Pre-Op order Sign op permit Sign op schedule NPO N/S 500ml Morphine 5ml IV st BP ： 137/72 mmHg PR: 102bpm SpO2: 100% BT: 36.3 degree E4V5M6

Assessment Internal bleeding, Spleen rupture (Gr II) L ’ t kidney rupture (Gr II) L ’ t pneumothorax with lung contussion R ’ t pneumothorax L ’ t radius fracture  Colle ’ s fracture

References Emergency Trauma Training Course ACLS 精華 3rd edition Sabiston Textbook of Surgery 17 th deition eMedicine 10/21/2002 Moore 1989

Thank you for your attention !!!!!!!