1. 外傷病例 Combined Conference
Presented by R 江秉晏
Supervisor MA 陳進明
Moderator MA 黃集仁

2. Triage at LSER 2011/06/17 08:59 Name: 詹X璟 Chart No: 21429057
Age and Gender: 53 y/o, male
Vitals: BT:36.4 PR:123 RR: SBP:96 DBP:68 E:4 V:5 M:6
檢傷主訴: Trauma Blue - 病患來診為高處跌落，胸部撕裂傷/擦傷，高危險性受傷機轉

3. Present Illness 在斜坡擋下滑的貨車(靜止到滑動)，被車撞入水溝約3公尺，有喝到水溝的髒水，貨車隨後跌入水溝壓到病患前胸
事故發生時間:2011/06/17 08:10
事故地點：街頭公路
外傷機轉：車禍
坐什麼車的?：行人
與什麼車相撞?：卡車
在斜坡擋下滑的貨車(靜止到滑動)，被車撞入水溝約3公尺，有喝到水溝的髒水，貨車隨後跌入水溝壓到病患前胸

4. Physical Examination Con’s: E4V5M6, clear
HEENT: neck: supple, conjunctiva: not pale
pupil: 3+/3+
Chest: anterior chest wall open wound 3 cm
breathing sound: diminished of left
heart: RHB, no murmur
Abdomen: soft and flat
bowel sound: normoactive
Pelvis: stable, no deformity
Extremities: freely, no open wound

5. 2011/06/17 09:08 (9 min) Initial orders Meperidine 1pc stat im
On chest tube: Fr. 32 fix 14 cm
CBC/DC, PT, aPTT ,一般備血: PRBC 4U and FFP 4U
ABG, Sugar, BUN/Cr, Na/K , AST/ALT, Amylase, Lipase, CKMB, Troponin-I
Ethyl alcohol (B)
IV WITH N/S RUN 100 CC/ HR
CXR
Consult Dept 胸腔外科 100/06/17 09:13 5

6. Questions What orders seemed to have been missed?
How would you value the secondary survey performed here?
Any information should also be obtained?

7. ATLS Primary survey and resuscitation
A (Airway and C-spine protection)
B (Breathing and ventilation)
C (Circulation with hemorrhage control)
D (Disability: neurologic status)
E (Exposure and enviromental control)
History (AMPLE)
Secondary survey
Finger to hole
From head to toe

8. PE about Thoracic Injury
Inspection: wound character (open, abrasion, laceration , penetrating), seat-belt sign, chest wall paradoxical movement, distended neck vein, cyanosis, scaphoid abdomen
Palpation: trachea displaced, crepitus
Percussion: tympanic or dullness
Auscultation: distal heart sound, murmur, decreased breath sounds unilaterally, bowel sound

9. Open Pneumothorax
cover the wound with a three-sided dressing so that air can escape but not enter
avoid complete occlusion: may convert into a tension pneumothorax

10. Indication for Chest tube

11. Initial Order 09:08 (9mins) Meperidine 1pc stat im
On chest tube: Fr. 32 fix 14 cm
CBC/DC, PT, aPTT ,一般備血: PRBC 4U and FFP 4U
ABG, Sugar, BUN/Cr, Na/K , AST/ALT, Amylase, Lipase, CKMB, Troponin-I
Ethyl alcohol (B)
IV WITH N/S RUN 100 CC/ HR
CXR
Consult Dept 胸腔外科 100/06/17 09:13
Oximeter; O2 supply
IVF challenge
FAST
EKG
Toxoid? Antibiotics?
C-spine x-ray
Pelvis x-ray

12. FAST coronal view of RUQ coronal view of LUQ suprapubic view
subxiphorid view: Pericardiac effusion? Tamponade? Wall motion?

13. 1st CXR Left 2nd~3rd ribs fracture. Right 3rd~9th ribs fracture
Consolidation in LUL and LLL of lung and ground glass opacity in RUL of lung, favor pulmonary hemorrhage.
Left pneumohemothorax and subcutaneous emphysema.
Status post left chest tube insertion with angulation.
Air stripes in the superior mediastinum, suspicious pneumomediastinum.

14. 2011/06/17 9:31 (32 min)
Vitals: PR 130 RR 28 BP 136/74
Whole body CT

15. Whole Body CT Conclusion: No intracranial hemorrhage
Multiple rib fractures and lower sternal fracture
Flail chest and anterior chest wall disruption
Left pneumothorax and bil lung contusions
Please recheck left chest tube positioning
Minor fracture of L3 at right T-process
Degenerative joint and disk disease of C-spine

16. 2011/06/17 09:52 (53mins)

17. ABG

18. Questions What are the major concern?
What needs to be done but has not been completed?
What would you expect to see in whole body CT? Rewarding? Justifiable?

19. 2011/06/17 9:54 (55 min) Tetanus toxoid(im) 0.5 PC STAT
Cefazolin sodium 2 PC stat iv
Gentamicin sulfate 1 PC stat ivf

20. 胸腔外科會診 會診報到日期: 2011/06/17 09:34 會診結束日期: 2011/06/17 10:13
Imp: flail chest ; L’t open pneumothorax
Suggestion:
1. suggest intubation with positive pressure, treat as flail chest
2. empiric antibiotics with rocephin and metronidazole, for prevent aspiration pneumonia
3. adjust chest tube since kinking noted
4. follow up ECG st and cardiac enzyme for heart contusion
5. well explain to family the possibility about heart contusion related arrhythmia, and the risk of sudden death

21. 2011/06/17 10:10 (61 min) Vitals: PR 136, RR 20, BP 118/75
RSI with midazolam, lidocaine & rocuronium
Intubation

22. EKG

23. 2nd CXR (post Endo) 10:41 Multiple bilateral ribs fracture.
Left pneumothorax S/P left chest tube insertion.
Multiple consolidation and ground glass oapcity in both lungs, favor pulmonary contusion, in progression.
S/P endotracheal tube in place.

24. 2011/06/17 11:03 (2 h 04 min) Vitals: PR 150, BP 72/46 (11:03)
On left subclavian CVP HAES 1pc stat, Dopamine line use 4pc in N/S 500ml run 20ml/hr

25. 2011/06/17 11:28 (2h 29min)
Vitals: PR 148; BP 77/37; SpO2 < 70%

26. 3rd CXR (post CVP) 11:34 (2h 35min)

27. CVS會診單 會診報到日期: 2011/06/17 11:28 會診結束日期: 2011/06/17 12:46 IMP:
Left open pneumothorax and flail chest was noted
severe lung contusion with ARDS at ER
Suggestion:
We will arrange VV mode ECMO insert at ER
Admitted CVSICU
On right femoral and neck CVP

28. Questions Would you agree with the diagnosis of ARDS?
Lung contusion, aspiration, or/and cardiac contusion?
Would you agree to put on ECMO?
What needs to be done but STILL hasn’t been completed?

29. While ECMO inserting ~ Vitals: PR 157 BP: 76/33 (12:49)
N/S 2000ml stat Transfusion: PRBC 2U
開刀房ECMO team 到急診( 12:58)
Vitals: PR 150 BP 63/39 (13:12)
Haes 1 pc IVF stat and Bosmin 0.1cc (endo) stat
Transfusion: PRBC 4U

30. 2011/06/17 13:32 (4h 33min) Vitals: PR 171, BP 102/47
ECMO inserted and admission to CVSICU

31. Brief Hospital Course
06/17 16:25 still hypotension after HAES 2PC sternal wound bleeding
Median sternotomy and check bleeding at OR
Left lower thoracic cage fractured with active internal mammary vessels bleeding
Pericardium opened to check if cardiac rupture. Intact cardiac structure without active bleeding was found

32. Brief Hospital Course 2011/06/20 =>Remove ECMO, VV mode
2011/06/21 =>Extubation
2011/06/24 =>Transfer to ordinary ward

33. Cohn SM, DuBose JJ World J Surg 2010; 34:1959–1970
Pulmonary Contusion: An Update on Recent Advances in Clinical Management
Cohn SM, DuBose JJ
World J Surg 2010; 34:1959–1970

34. Image
CXR: consolidation patterns, ‘‘traumatic pneumonia’’, typically appearing within 4–6 h after injury and ‘‘vanishing’’ within a few days
Chest CT: superior to CXR, helpful in predicting the need for MV and the likelihood of pneumonia or ARDS.

35. Management Primarily supportive
Adequate oxygenation and ventilation: high-frequency ventilation, prone positioning, NO inhalation, prostaglandin infusion, even ECMO

36. Management
Pain control: epidural catheter better than iv or oral analgesics
Flail chest: early surgical fixation, better in intubation time, ICU time, pneumonia rate
Corticosteroid: no clinical evidence

37. Consciousness: GCS, description of responsiveness (e. g
Consciousness: GCS, description of responsiveness (e.g., lethargic and not following verbal commands)
Vitals (check pulses and respiration and estimate pressure BY YOURSELF!)
Head: open wounds, bleeding, deformity, crepitus, bony continuity, Battle’s sign, raccoon eyes, epistaxis, ear bleeding, floating palate, malocclusion
Eyes: pupil sizes, symmetry and reaction to light
Neck: tenderness, crepitus, tracheal deviation, laryngeal injury
Chest: symmetry in expansion, crepitus, tenderness, open wound, flail chest, hyperresonant/dull percussion, muffled heart sounds
Abdomen: Rigidity, distension, tenderness
Pelvis: stability, blood in meatus
Digital rectal exam: blood in rectum, high-riding prostate, anal tone
Extremities: open wound, crepitus, bony continuity, distal motion/sensation/pulsation, deformity
Neurological: lateralizing signs, sensory level, muscle power, reflex-es

38. Take home message
Secondary survey: can’t afford to miss any abnormality
Shock unstabilized: can’t afford to happen
Lung contusion, aspiration, or/and myocardial contusion – does it matter?
ECMO for lung contusion? Should attempt other treatment modalities before going there

39. Thanks for your attention ~

41. Classification of blood loss41

42. Echocardiogram
Information: global cardiac function, chamber function and wall motion, valvular function, and EF.
Formal echocardiography should be used in patients with elevated cardiac markers, dysrhythmias, or myocardial dysfunction.=> Consult CV 42