1. Case Report by intern 莊凱峻

2. Patient profile Name: 李 X 焜 Gender: male Age: 80 y/o Chart No.:12885542 Date: 96.6.7 pm4:50

3. Chief complain Fell down from height (3F  floor) 96.6/7 pm4:22

4. Present Illness EMT, on collar Conscious: clear,E4V5M6 Pale, cold sweating TPR: 34.3^, 98/min, 14/min BP:168/127 mmHg Neck stiff, Chest pain, Abdomen discomfort

5. Present Illness Right face abrasion, ecchymosis Right elbow open fracture (typeII) Right forearm abrasion (bleeding) Left wrist deformity (r/o close fracture) Right leg deformity (r/o femoral head fracture, pelvis fracture)

7. Past History BPH (suspect Prostate CA, PSA>4, but free PSA/total PSA<0.2 ) HTN (-), DM (-), HBV (-), HCV(-) Glucose intolerance Cardiomegaly

8. Management (16:50) IV, O2, Monitor (SpO2 86%) Tetanus Toxoid Blood examination (CPK:306, Tropo-I:0.21, CK-MB:86.4) Ice packing Demeral Cefazolin +Aq-dest (IV push) CXR (portable) Right, left wrist X-ray Right elbow X-ray L-spine X-ray

9. Right femoral X-ray Pelvis X-ray Brain+ facial bone CT L/R 1BT Wound care, splint use Check vital sign

11. (17:34) BP:118/89 mmHg, pulse:79,conscious change Dyspnea Circulation:pale On endo with N/S 1BT Citosol, Genso, Adrenalin On CVC Arrange PRBC 4u 烤燈 use

12. (17:45) BP:77/52 mmHg, pulse:132, Conscious not clear Circulation: pale Gelofusine 2 BT L/R 2BT, N/S 1BT

13. (17:52) BP:64/33mmHg, Pulse:127 Conscious not clear Circulation: pale Gelofusine On foley (18:00) BP:48/26mmHg, pulse:92 Conscious not clear Circulation: pale Adrenalin CPR Sign DNR

14. (18:10) DC brain CT+ Abd CT DC all X-ray FAST echo (susp. pneumoportal) (18:20) BP:55/32mmHg, pulse:110/min Conscious not clear Circulation: pale PRBC:2u

15. (18:30) recheck BP, Pulse BP:50/24mmHg, pulse: 101 Conscious not clear Circulation: pale Arrange portable CXR (19:--) BP: not available, Pulse: not available EKG: standstill Expire at 19:25

16. Right 1st rib frx Right 8th rib frx Left 7th rib frx

17. Diagnosis Hypovolemic shock r/o retroperitoneal hemorrhage Right elbow open fracture Left wrist close fracture r/o Right femoral head fracture r/o pelvis fracture Chest contusion with rib fracture r/o ICH r/o pneumoportal

18. Discussion

19. Hepatic portal venous gas (HPVG) (Pneumoportal) 肝門靜脈氣體 results from mesenteric vessels occlusion, leading to intestinal necrosis with a high mortality septic and hypovolemic shock, which was superimposed on intestinal distension and this resulted in intestinal hypoperfusion and submucosa damage. Use of imaging studies, HPVG is more frequently detected than before Diagnosis: Echo, CT better than X-ray surgical intervention (necrosis, sepsis, peritonitis) aggressive supportive care, including antibiotics and fluid supplement