1. Case Conference 指導老師 李維哲 醫師 Intern 莊淵智 2007.7.3

2. Patient ’ s profile Chart NO. : 10056413 Name : 王 XX Age : 20 y/o Sex : male Date of ER visiting : 2007.6.30 (19:32pm)

3. Condition at Scene Chief complaint : racing car crash(80km/hr) to the enclosure Vital sign : HR= 66 bpm, BT= 35.7 ’ C RR= 16/min, BP= 110/70 mmHg GCS : E4V5M6

4. Seat-belt mark

5. Physical examination Head : nil Neck : nil Chest : left side pain, no dyspnea breathing sound: bil. clear Abdomen : left side pain

6. Past history Asthma in childhood Deny any other systemic diseases

7. Management (6/30) 19:55 CBC. GOT. GPT. BUN. Cr. Na. K. Sugar.CBC. GOT. GPT. BUN. Cr. Na. K. Sugar. Amylase. Lipase. CK. CK-MB. Troponin-I Chest X-ray, 12-lead EKGChest X-ray12-lead EKG N/S 1 BT IVD. Ice package. O 2 2L/min. NPO 20:20 Demerol 40mg IM 21:30 N/S 1 BT IVD 22:45 Dacoton (pain-killer) 1# qid x 3 days Sketa (muscle relaxant) 1# qid x 3 days Serenal (Oxazolam) 1# qid x 3 days Strocain 1# qid x 3 days

8. Management (7/1) 03:20 Constipation  EVAC 1 tube enema 06:35 General weakness  Finger sugar (246). BP= 100/57 mmHg, HR= 125 bpm + lip pale  CBCCBC 07:25 Dyspnea  R/O internal bleeding  Chest and Abdominal CT with contrast  N/S 1 BT 07:40 BP= 98/56 mmHg, HR= 140 bpm 08:10 BP= 96/56 mmHg, HR= 110 bpm

9. Management (7/1) 08:50 BP= 119/73 mmHg, HR= 109 bpm, GCS=E3V5M6  Check PT. PTT. BP. HRPT. PTT  Consult Radiologist and GS 09:15 IV over  N/S 1 BT + Bain 1 Amp IVD 09:50 BP= 116/67 mmHg, HR= 118 bpm, SpO 2 = 97% 10:35 NPO, absolute Bed-rest, on Foley 備 PRBC 4u, PLT 12u, FFP 4u 待床 SICU 11:40 BP= 98/63 mmHg, HR= 127 bpm, recheck 血型  Gelofusine 1 BT IVD

10. Management (7/1) 13:10 BP= 112/69 mmHg, HR= 123bpm  輸 PLT 12u 14:05 BP= 117/67 mmHg, HR= 119 bpm, BT= 37.3 ’ C, SpO2= 98%  輸 PRBC 2u, 於 16:30 繼續輸 PRBC 2u 19:50 BP= 121/70 mmHg, HR= 105 bpm  PRBC 輸畢, p ’ t 無不適反應  開始輸 FFP 4u 21:20 Itchiness + low abdominal and right lower leg rash  Hold FFP ( 剩 NO.3, NO.4 1/2 bag)  Vena-Ca-B6 1 Amp Saxizon (Hydrocortisone) 1/2 vial

11. Management (7/1-7/2) 22:10 BP= 123/66 mmHg, HR= 96bpm, BT= 37.7 ’ C 22:40 Itchiness subsided  繼續輸剩餘的 PRBC 1/2 bag 23:10 BP= 131/64 mmHg, HR= 100 bpm PRBC 輸畢, p ’ t 無不適反應 06:00 BP= 143/89 mmHg, HR= 100bpm, BT= 37.4 ’ C  CBCCBC

12. Management (7/2) 09:00 BP= 159/74 mmHg, HR= 99bpm, Hb= 8.8 mild dyspnea, postural dizziness  Blood transfusion ( 備 whole blood 2u + PRBC 2u) 10:30 Vital sign stable, Breathing sound: bil. clear 10:50 BP= 128/71 mmHg, HR= 89 bpm  Rideron (4mg) 1 Amp + Allecium B6 1 Amp  輸 A/+ whole blood 1u 11:50 Taita NO.4 1 BT 12:25 Patient complain dyspnea, SpO 2 = 98%, RR= 28/min  Saxizon 1/2 vial, O 2 2L/min use

13. Management of Traumatic Retroperitoneal Hematoma Ann Surg. 1990 Feb;211(2):109-23.

15. Operation ?  based on mechanism of injury + hemodynamic status + extent of associated injuries Opened  Midline, lateral paraduodenal, lateral pericolonic not associated with pelvic, and portal hematomas are after proximal vascular control has been obtained, if appropriate. Not opened  Selected retroperitoneal hematomas in the lateral perirenal and pelvic areas  Retrohepatic hematomas without obvious active hemorrhage

16. Penetrating trauma  most still opened  Exceptions : isolated lateral perirenal hematomas that have been carefully staged by CT and some lateral pericolonic hematomas Blunt trauma  without obvious active hemorrhage  not opened

17. Management of traumatic retroperitoneal hematoma J Chir (Paris). 2004 Jul;141(4):243-9

18. Traumatic retroperitoneal hematoma (RPH) Zone 1 (central) : esophageal hiatus to the sacral promontory Zone 2 (lateral) : lateral diaphragm to the iliac crest Zone 3 (pelvic) : retroperitoneal space of the pelvic bowel Surgical exploration  persistent hemodynamic instability, mechanism of injury, location Urgent surgery  upper central area (Zone 1) + penetrating trauma + injury to the great vessels Evaluation : CT and/or angiography

19. Thanks for your attention!!

20. EKG

21. Chest X-ray Back

22. Lab Data (6/30, 20:10PM) WBC (10 3 /ul) 17.16 Amylase (U/L) 55 RBC (10 6 /ul) 4.87 Lipase (U/L) 19 Hb (g/dl) 15.0 BUN / Cr(mg/dl) 12.6/0.8 HCT ( ％ ) 43.2 Na (mmol/L) 140 MCV (fl) 88.7 K (mmol/L) 4.6 PLT (10 3 /ul) 150CPK (U/L)277 Sugar (mg/dl) 152CK-MB (U/L)7.1 GOT / GPT (IU/L) 27/29 Troponin-I (ng/ml) 0.01 Back

23. Lab Data (7/1, 06:39AM) WBC (10 3 /ul) 24.72 RBC (10 6 /ul) 3.63 Hb (g/dl) 10.8 HCT ( ％ ) 32.4 MCV (fl) 89.3 PLT (10 3 /ul) 207 Back

24. Lab Data (7/1, 08:57AM) PT (p) 12.0 PT (c) 10.9 INR 1.25 PTT (p) 25.4 PTT (c) 28.6 Back

25. Lab Data (7/2, 07:00AM) WBC (10 3 /ul) 13.02 RBC (10 6 /ul) 2.92 Hb (g/dl) 8.8 HCT ( ％ ) 25.1 MCV (fl) 86.0 PLT (10 3 /ul) 126 Back