Case Presentation Intern 蔡孟峰

Chief Complaint Traffic accident last midnight(06/03), transferred from “ 劉光雄 ” Hospital

Present Illness The 21-year-old male is well-being before. Last night, he went out with his friends, sitting in the middle of the backseat. Around 22:00, the car crashed a wire pole. He didn’t know anything until he woke up in “ 劉光雄 ” hospital. Several management were done there.

Present Illness Diagnosis at 劉光雄 hospital Consciousness drowsy Head injury with brain swelling Right thigh painful deformity Right femur fracture Right leg 固定在護木位置 Then, he was transferred to our ER for further management.

The Status on Arrival Consciousness : alert, E4V5M6 Respiratory Rate : 10 ~ 24 / min Pulse Rate : 127 /min Blood Pressure : 163 / 93 mmHg Body Temperature : 36.8 o C At ER, right femoral fracture and dyspnea were told. dyspnea were told.

Initial Assessment A : patent airway B : spontaneous breathing C : radial pulse (+) Pulse rate : 127/min Blood pressure : 163/93 mmHg D : E4V5M6 E : trauma at Left lower pulmonary area Epigastric area Right upper femoral area

Focused history Allergic : denied Medication : denied Past medical history : denied Last meal : unknown Events: traffic accident

Plan CBC GOT/ GPT/ BUN/ Creatinine/ Sugar/ Na/ K PT/ APTT Ethanol Cross matching/ PRBC 2U Lactated Ringer IVD : 500c.c. NPO Nasal Cannula 12 lead EKG 頸圈固定 X-ray Skull AP, Lateral Chest AP Spine AP, Lateral, Neck Femur Pelvis CT scan : abdomen 適應症 : R/O internal bleeding

Available Lab Data WBC(10 3 /μl) RBC(10 8 /μl) 5.22 Hgb (g/dl) 10.6 Hct (%) 34.9 MCV ( fl ) 66.9 MCH (pg) 20.3 MCHC (g/dl) 30.4 PLT (10 3 /μl) 151 Neut (%) 88.9 Eosin (%) 0.1 Baso (%) 0.1 Lymph (%) 7.2 Mono (%) 3.7

Available Lab Data GOT (μ/L) 76 GPT (μ/L) 59 BUN (μ/L) 11.9 CREA ( mg/dl) 0.91 Na (Meq/L) 139 K (Meq/L) 3.78 Cl(Meq/L)114 Sugar (mg/dl) 193 Ethanol (mg/dl) <5.0 PT (p) 14.2 PT (c) 10.5 INR1.50 PTT(p)32.1 PTT(c)29.7

Management 01 : 00 Gelofusine 500 c.c. IV PRBC 2U st 01 : 10 SpO 2 = 89% O 2 : 3 l/min 01 : 15 BP : 138/66 mmHg, pulse : 136 /min 開始輸 PRBC

Management 01 : 25 BP : 123/53 mmHg, pulse : 137 /min, SpO 2 : 100% X-ray survey 01 : 30 CT-scan (abdomen) 適應症 : R/O internal bleeding ?? FAST scan Fluid accumulation over Morison’s pouch

Image

劉光雄醫院

Abdominal CT

Report Splenic laceration with hemoperitonum. Left pneumothorax. Contusion hemorrhage at both pulmonary lower lobes. Pelvic fracture at bilateral superior rami of pubis, right ilium and right aspect of sacrum. Soft tissue swelling over left lower flank.

Management 01 : 55 O : internal bleeding on Foley 02 : 00 BP :120/54 mmHg, HR : 123 /min, SpO 2 : 100% BP :123/49 mmHg, HR : 144 /min, SpO 2 : 98% L/R 500 c.c. IV st BT PRBC 2U FFP 6U Transamin 2Amp IV Vit C / Amp IV Hematuria

Management 02 : 20 BP : 100/40 mmHg, HR : 170 /min R/O internal bleeding, hematuria Admission to GS Cefazolin 1g vial IV Gentamicin 80mg/ Amp IM 7ESI-2 On CVP 顏面縫合 Nylon 6-0

Management 02 : 35 BP : 132/51 mmHg, pulse : 119 /min 02 : 45 BP : 121/63 mmHg, pulse : 122 /min, BT : 35.6 o C 離開 ER

Diagnosis at ER Right femoral shaft fracture AIS=2 R/O linear laceration AIS=3 R/O acetabular fracture, bilateral Left occult pneumothorax AIS=3 R/O pubic ramus fracture Renal contusion R/O U-B rupture ISS=22 ISS=22