Case Presentation Presenter : Intern 黃曉禹

Brief History referred from 小港 Male 54y/o Conscious : clear??, E4V5M TA close pelvic fracture 左前胸, 左臉, 左手, 左 腳 開放性傷口紗布 小港 6600 cc fluid 1 2-way CVP line 1. PRBC 1U 2. Gelofusin 1 BT 2 peripheral line right hand IV with N/S right foot iv with N/S

1st assessment ( ) Airway: patent no need neck protect Can talk Breathing:10-24 obstruction: nil foreign:nil tracheal deviation: nil Circulation :74/40 skin: pale temperature warm moist : normal Pulse:normal Bleeding : ?? Disability : E3V5M6 GCS=14 Expose / Enviroment

2nd assessment Allergy : nil Medication : 胃藥 Past illness: 胃痛 Last meal : Events : Traffic accident, crushing injury 小港 H suggest angiography & embolization General survey : Left ant face, chest, left upper limbs & lower limbs open wound, no active bleeding

Initial management 1440 O2 4L/min blood exam n/s 1000ml ivd on EKG monitor On oxymeter 備血 PRBC 6U FFP 6U PLT 12U 1457 arrange angiography, sign permit 1440 SaO2 94% 1500 BP 95/50 p90 N/S 1 BT 1515 BP 84/38, p88 Send angio room Pelvic fracture Force? 前後 -pelvic unstable + threatening hypotension 側面 - bladder & ureter injury 垂直 - pelvic unstable Volume status 6600cc in about < 3hr Hypovolemic status Fluid resuscitation 3:1 crystaloid : blood loss Crushing injury>3:1(more crystaloid) Progressive bleeding <3:1 (more blood)

小港 lab data WBC 6280/ul RBC 5.2 HGB 15.4 HCT 45.9 PLT 184 PT P/PT C= 11.9 / 10.7 PTT P/ PTT C = 28.7 / 1.65 GOT/GPT 31/29 BUN/CREA 22.8/1.65 NA/K=137/3.8 GLU 245

1440 blood exam Distal upper limb Proximal upper limb 250 Distal lower limb 500 Proximal lower limb 1000 Pelvic

小港 CT

Angiography & embolization

angiography The aortogram, bilateral internal iliac arteriography reveal extravasation via the left superior gluteal artery.

2nd management --back from angio room -- continue bleeding 1720 consult OW whole blood 10 U 1740 BP 112/78 P102 PRBC 2U 無不適 DOPAMINE 2 amp + N/S 1 BT keep 10 gtt/min 1810 P RBC *2 BP121/76 P102 FFP 2U * 2 P RBC * N/S 1BT + transamine 1 amp 1905 BP 109/72 P103 Sao2 100%

2nd management --back from angio room -- continue bleeding 1910 sign permit NPO N/S 1 Bt + trasamine 2amp IVD chest-x-ray PA view 1930 BP: 107/59 PR BP: 99/59 P BP 98/53 P120 SaO2:100% 2040 blood exam ABD CT enhanced 2050 sent p't to CT room 95/50 P128 Sao2 100% Source of bleeding ?? Open wound 左前胸 左臉 左手 左腳

Image 2 Chest x-ray Abdomen CT CBC

3th management -- prepare to OR 2110 BP 120/55 P130 SaO2 100% PLT 輸畢無不適 2112 sinus tachycardia 2115 whole blood consult GS 2130: 97/62 P68 Sao2 100% non-rebreathing mask use 10 L/min

3th management -- prepare to OR 2135 s: dyspnea Sao2 100% On endo citosol + aq dest1amp-- >5u iv on endo fix 23cm PRN surgeon on ventilator TV 600ml rate 8 times/min 2142 EKG sinus tachycardia 2200 BP:104/69 PR118 whole Blood 2215 BP101/69 PR138 sent to OR & 15ESI 1-8 On endo

OR splenectomy

Impression Pelvic fracture Hypovolemic shock Spleen laceration Left Kidney parechyma injury Mixed type acidosis, metabolic acidosis + respiratory acidosis

Thanks for your attention