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Case Conference- 急診外科 Presenter: Int. 黃士財 Director: 林杏麟醫師 Date: 2006-09-05
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Patient profile: Name: 許╳恩 Gender: male Age: 10 years old ID: 23088220 Time: 2006-09-02, around 6:00pm
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Pre-hospital Assessment Incident: crushed by a sport utility vehicle near 龍華國中 Brought by an 119 ambulance with neck collar, Spinal Broad, and Simple mask (O2: 10L/min) 否 24 130 155/75 E1V1M1 否 20 134 157/72 E1V1M1 抵院時基本狀態: Respond to pain, RR: 10~24/min, BP: 152/110 mmHg, Pulse: 149 bpm, BT: 37.2 ’ C , GCS score: E1V1M1
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Primary ABCD
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Airway Neck collar Airway obstruction sign: Cyanotic,
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Breathing Respiration rate:18/min → On simple mask, O2 : 6L/min No trachea deviation Breathing sound: bilateral rale and rhonchi Subcutaneous cripitus: right side Echo finding: no lung sliding, 霧霧的 → Right thoracostomy was performed at 6:25pm SpO 2 : 94%
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Circulation Check four limbs pulse: BP: 左手: BP: 130/80mmHg, pulse: 142/min 右手: BP:146/72mmHg, pulse: 134/min 右腳: BP: 骨折無法測量, pulse: OK Peripheral circulation: Skin color: red Temperature: warm Capillary refilling time: not performed Bleeding: 懷疑胸腔內持續出血 FAST: Morrison ’ s pouch, Splenic fossa, cul-de- sac, pericardium, no fluid acclumination.
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Disability and Exposure GCS score: E2V2M4, 總分: 8 Pupil: sluggish, right 5mm/5mm 移除衣物,在背部發現有一大片 Abrasion wound.
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Menagement Neck collar, Simple mask 6L/min, Pulse oximetry, EKG monitor, Peripheral line N/S 1 bot On chest tube, right and left side Lab exam: CBC, PT/PTT, Sugar, BUN/Cr, Na/K, GOT/GPT, CPK/CKMB/Tropo-I Image: X-ray: Chest,Elbow (R), Humor (L), Low leg (R), Femur (R), Pelvis CT: C-spine, Head (with and without contrast), chest, abdomen
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Lab data 9/028:37PM Temp37.2 PH7.303 PCO245.5 PO2109.4 HCO3-22 BE-4.5 SBC20.6 Becf-4.4 %O297.5 9/2 (6:25pm) 9/4 WBC15.9411.05 RBC5.014.41 HgB13.212 HCT40.6%36.4 MCV81.882.5 MCH26.326.8 MCHC32.532.4 PLT329169 RDW-CV13.614.4 RDW-SD40.543.9 9/029:00PM PTp/PTc13.4/10.8 PT(INR)1.35 PTTp/PTTc31.9/28.2 Sugar221mg/dl BUN/Cr58/0.69 Na/K141/3.21 GOT/GPT82/44 CPK579 CK-MB219.7 Tropo-I0.018
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Image Finding
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Image finding CT of Chest: 1.Bilateral pneumothorax and suspicious bilateral hemothorax s/p right chest tube insertion with subcutaneus emphysema at right lateral chest wall. 2.Deformity of left 5th, 6th, 7th, 8th and 9th ribs, suspect old fracture. CT of head: 1.Subgaleal hematoma at left temporo-parietal scalp. 2.Left maxillary hemosinus; sphenoid, right frontal,right ethmoid and right maxillary sinusitis/hemosinuses.
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19:15 BP: 142/66mmHg, PR: 134/min 19:45 BP: 141/96mmHg, PR: 142/min conscious: clear (while performed CT) 20:10 BP: 140/70mmHg, PR: 135/min BT: 36.6 ’ C, sPO2: 95% Admitted to 5C at 9:15, all purpose 35% 10L/min
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急診初步診斷 Traumatic left pneumothorax and right hemopneumothorax /c lung contusion Traumatic asphyxia Right femoral bone fracture Left upper arm crushing injury Back contusion /c abrasion Head injury /c scalp abrasion
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Current condition Remove bilateral chest tube on 9/4
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