1. ER / Case Presentation Int 陳姿吟

2. Patient Profile 49 y/o male Admitted Date ： 95/10/11 15:18

3. Pre-hospital phase Transferred from 輔英 H Assessment ： R/O organophosphates intoxication Head injury Management ： On endotracheal tube brain CT C-spine AP, lateral 、 CXR 、 Pelvic X ray right leg X ray On NG→ green liquid N/S ： 2000ml toxoid Atropine

4. Emergency Department Phase 10/11 15:18

5. Primary ABCDE Airway On endotracheal tube Breathing RR ： 10-24/min breathing sound ： ? SpO 2 ： ? Circulation BP ： 176/82 mmHg PR ： 75 /min

6. Primary ABCDE Disability GCS ： E2VeM2-3 Light Reflex ： ±/±, 1/1 Exposure/ Environment BT: 35 ℃ Epistaxis Abrasion wound ： 2cm*2cm on the forehead 4cm*4cm on the right chest wall 10cm*2cm on the right knee

7. Problem List BP ： 176/82 mmHg GCS ： E2VeM2-3 Light Reflex ： ±/±, 1/1 Breathing ： Right upper lung lobe collapse → ？ foreign body underestimate on CXR Multiple abrasion wounds, epistaxis On NG→ green liquid

8. Initial Management On ventilator ： TV 600ml, RR18/min, FiO2 100 ﹪, A/C mode EKG, Pulse Oximeter Lab

9. Brain CT at 輔英 H

10. Chest PA at 輔英

11. C-spine at 輔英

12. Pelvic

13. Right leg

14. Data WBC ： 3360 RBC ： 5.66x10 6 Hb ： 15.4 Hct ： 48.3 Plt ： 257 BUN/CREA ： 13.5/1.51 Na/K ： 142/3.05 GOT/GPT ： 94/87 Ca ++ ： 4.85 PT ： 9.7/11.1 INR ： 0.79 aPTT ： 26.8/29.2 Sugar 329 CRP 0.28 Ammonia 94 Ethanol 2.3 Cholinesterase 338 Paraquat test negative urine BZD 369.60 ABG ： pH 7.141 PCO2 63 PO2 68.4 HCO3- 21 Base excess –9 ﹪ O2sat 85.1 ﹪

15. Initial Impression Consciousness disturbance r/o organophosphates intoxication, BZD over dose Right upper lung lobe collapse foreign body induced, r/o tooth

16. Secondary ABCDE 16:00 BP 178/88 PR: 73 SpO2: 87 ﹪ 16:30 BP 173/87 PR: 75 SpO2: 86 ﹪ AMPLE Tubes and fingers in every orifice Head to toe evaluation

17. Following Conditions and Managements 16:30 arrange brain CT with enhancement chest CT with enhancement C-spine CT with enhancement

18. Brain CT

19. C-spine CT

20. Chest CT

22. 16:50 BP158/88, PR 88, SpO2 89 ﹪ 17:10 BP170/86, PR 86 E1VeM1 urine output ： 450ml NG 250c.c, green management ： N/S 1 bot PAM 10 Amp keep 20gtt/min

23. 18:30 BP168/88, PR 89, SpO2 88 ﹪ E2VeM2-3 management ： N/S 1 bot 18:40 pupil size: pin point(ou) check 12 lead EKG 轉內科 20:15 BP151/96, PR 96, SpO2 87 ﹪ 轉內科 ICU

24. 10/11 On CVC E1VeM1 10/12 E1VeM1 Arrange bronchoscope to remove foreign body

25. 10/12 E1VeM1 poor urine amount liver function downhill( GOT/GPT 6945/6405, PT INR 2.18) DIC profile ： FDP （ - ）, fibrinogen 247 D-dimer 457 thrombocytopenia

26. 10/13 E1VeM1 Hepatoglobin 51.8 BUN/Cr 51.8/5.77 Cholinesterase 448 TCA ＜ 0.1 PLT 9000/ul

27. Thanks for your Attention!