1. Combine Conference 外科/急診 Reporter : ED R4 黃建雄 Supervisor :李景行醫師
April 8, 2014

2. General data 42 y/o, male Time of arrival: 2013/12/07 20:59
Triage 檢傷一級 trauma blue
病患來診為自2樓墜樓
Vital signs
T:35 P:60 R:19
SBP:89 DBP:40
E:4 V:5 M:6

3. Chief complaint
Fell down from 3 meters (一層樓高) high

4. Present illness no head contusion, no ILOC back pain:+
denied chest or abdominal pain
no SOB
alcochol consumptiom:+

5. Past history
DM-
HTN-

6. Physical Examination General appearance : ill
Conscious : clear Pupil size : 3+/3+
HEENT not anemic, anicteric
Neck no jugular enlargement
Chest: bil BS clear
Heart : RHB , no murmur
Abdomen soft and flat, normo-active BS
Extremities: free movable, no gross deformity
Back no tender
Skin: no open wound

7. What should we do now?

8. ATLS Principle Primary survey A Airway and C spine Secondary survey
B Breathing and ventilation
C Circulation and hemorrhage
D Disability and neurologic
status
E Exposure and Environment
Secondary survey
在此SLIDE中 應一一對照出此病人的相對應問題 ( by oral presentation, discussing with audience)
my opinion as following
A: airway seems OK, no facial trauma, no hemoptysis / hematesis; C spine no check
B: breathing, not OK, but pulse oximeter? Under room air? Suspected tension pneumothorax,? What about tracheal position? Chest percussion; if highly suspected should do the needle decompression at firstly, or portable chest X ray?
C : not good, bleeder?
fluid resuscitation, pt got at least class III blood loss, should replacement with blood transfusion as soon as possible
D: seems OK
E: checking? How about pt’s back?

9. Hypovolemic shock: most in trauma patient
Class 1
Class 2
Class 3
Class 4
Blood loss (ml)
Up to 750
750~1000
1500~2000
>2000
Blood loss (%)
Up to 15%
15%~30%
30%~40%
>40%
Pulse rate
<100
100~120
120~140
>140
Blood pressure
normal
decreased
Pulse pressure
Normal or increased
Respiratory rate
14~20
20~30
30~40
>35
Urine output (ml/hr)
>30
5~15
negligible
CNS/mental status
Slightly anxious
Mildly anxious
Anxious, confused
Confused, lethargic
Fluid replacement
crystalloid
Crystalloid and blood
這個TABLE 是舊版的 NEW的多一個COLUMN: initial fluid replacement

10. Non-hemorrhagic shock
Neurologic shock
--disruption of the autonomic pathways within the spinal cord
--central nervous system damage (brain injury, cervical or high thoracic spinal cord)
--Tx: fluid or inotropic

11. Non-hemorrhagic shock
Obstructive
--Cardiac temponade
--Tension pneumothorax

12. Back to our patient 20:59pm (0min)
CBC, WBC/DC, PT, APTT
BUN/Cr, ALT, Na, K, sugar
Ethyl alcohol
On monitor
Prepare PRBC 2U
IV challenge 1000cc stat
IV with N/S 1000ml run 80cc/hr

13. Chest PA view
C-spine lateral view
T-L spine lateral view
CT (contrast +/-) of abdomen and chest
Keto 1pc IM

14. Do you agree?
What will you do?

15. On neck collar
More aggressive fluid resuscitation
Warm IV fluid
FAST
Contact Trauma doctor

16. Image 21:10 pm (11mins)

17. CT finding
1.Spleen laceration with active bleeding and hemoperitoneum 2.Left 9th-11th ribs close fracture

18. Imp: 1.Spleen laceration with active bleeding and hemoperitoneum
2.hypovolemic shock
3.Left 9th-11th ribs close fracture

19. 21:22pm (23min)
開立病危通知單 : 脾臟破裂
Consult 外傷小組
Vitals after 1000 N/S challenge
BP:90/44 HR:70

20. Can J Surg 2008;51(6):464)

21. Stable or Unstable TAE or Laparotomy
Next step
Stable or Unstable TAE or Laparotomy
Contact radiologist 也可以了解prepare 需要多久時間!!

22. 21:47pm (48min) TR-GS consult sheet completed Arrange TAE
B/T with PRBC 4U stat(緊急備血)
IV challenge with N/S 1000cc
stat(2nd)
IVF2: N/S 1000ml run 120cc/hr
Admitted to Trauma ICU

23. Lab data WBC 10900 RBC 3.79 seg 36 Hb 13.9 lymphocyte 55 Hct 39.1
monocyte 8
MCV
103.2
eosinophil
MCH
36.7
MCHC
35.5
P.T
11.6
RDW
15.1
INR
1.11
Platelet
96K
APTT
26.3

24. Lab data
BUN/Cr
7/1.31
sugar
159
ALT 60 Na
144 K
2.03
alcohol
276

25. 22:14pm (1h 15m) Vitals: BT:36℃ pulse:81 RR:16 BP: 77/41
IVF 1 renew: N/S 1000ml + KCL 40meq run 80cc/hr
KCL 1pc in N/S 100cc run 20 mins
On right neck Large bore
B/T with PRBC 2U and FFP 2U stat (緊急備血)

26. Stable or Unstable?
Contact radiologist 也可以了解prepare 需要多久時間!!

27. 22:35pm (1h 36m) TAE or Laparotomy? Vitals before TAE:
BT:36 pulse:86 RR:19
BP:66/41
TAE or Laparotomy?

28. 22:40pm(1hr 41m)送TAE 23:30pm(2hrs 31m)完成
Full text:
Angiography of celiac trunk, splenic artery and transaterial embolization show:
1. Multiple small contrast extravasation in the upper pole of spleen.
2. Transarterial embolization was performed after superselectively cannulated into the superior and middle branches of splenic artery with coils. (4x2 mm-COOKx 3, 3x2mm-COOK x 1, VortX-4x4mm x 1)
3. The subsequent post-TAE angiography of the splenic artery showed successful cessation of the bleeder.
4. Patient tolerated this procedure well.
IMP:
Splenic laceration with contrast extravasion
post TAE with coils.

29. Vitals during TAE BT HR RR BP 23:00 36 125 19 156/46 23:09 122 74/39
23:17
35.8
118 20
53/36
23:30
101
58/35
23:32
110
61/47

30. 23:54pm after TAE Cons change, FS:281 Dyspnea and SOB
Blood arterial gas:

31. 00:10am (3hrs 11mins) Intubation Jusomin 4pc IV stat
B/T with PRBC 4U and FFP 2U stat
00:23pm (3hrs 24m)
Sudden bradycardia and then PEA
CPCR  sucess after bosmin 3pc
IV with N/S 1000cc challenge

33. What should we do now? Re-evaluate!! ACLS Airway patency?
Lung contusion or delayed hemothorax? Pneumothorax with tension?
Circulation, other ongoing bleeding? Obstructive shock?
Cons change with CO2 retention – pupils? brain CT?
口述應該re-evaluate 甚麼? Tension pneumo, endo position, BS,
cardiaqc tamponade, quick bed side echo
hypothermia? Un-control bleeding?

34. Afterward… Dopamine line (00:42am) Levophed line (1:16am)
Arterial blood gas after intubation:

35. FAST: increasing amount of ascites
Consult Trauma doctor f/u (1:40am)
2:18am B/T with FFP 2U and PLT 24U stat
2:25am: emergent laparotomy

36. OP record 2:52am enter OR, 3:23am time out,7:30am手術結束
Patient had persisted bradycardia and hypotnesion episode, family decide DNR and patient expired on 9:45am 12/8 in ICU

38. Take home message
需熟悉出血性休克的處理。除了crystalloid fluid給予，必要時須盡早給予輸血，並避免coagulopathy，尤其病患可能為alcoholism
當外傷病患由stable condition轉變為unstable condition時，需立刻重新評估並考慮改變治療方向。
根據ATLS, hemodynamic unstable patient合併hemoperitonium，需接受emergent surgical exploration。

39. Thank you for your attention !