1. Case presentation 96.09.04 Intern 胡學錦

2. Personal profile Name : 吳 O 民 Name : 吳 O 民 Gender : male Gender : male Age : 46 years old Age : 46 years old Chart number : 16762291 Chart number : 16762291 Arrival date at ED : 96/08/20 Arrival date at ED : 96/08/20 Time : 04:15 am Time : 04:15 am

3. Injury mechanism Suffered from a traffic accident with drunken state this morning (04:00am) Suspect drunken driving Suffered from a traffic accident with drunken state this morning (04:00am) Suspect drunken driving 現場生命現象 : drowsy and irritable (E3V3M4) 現場生命現象 : drowsy and irritable (E3V3M4) CC: Alcoholism with Traffic accident CC: Alcoholism with Traffic accident

4. Pre-hospital evaluation and management Sent to KMUH ER by 119 Sent to KMUH ER by 119 Head :ILOC(?), dizziness(?), headache(?), nausea/vomiting(?), amnesia(?), vertigo(?) laceration wound over r’t upper eyelid and earlobe Head :ILOC(?), dizziness(?), headache(?), nausea/vomiting(?), amnesia(?), vertigo(?) laceration wound over r’t upper eyelid and earlobe Neck: pain, stiff, soreness…(?) Neck: pain, stiff, soreness…(?) Chest: pain, dyspnea…(?) Chest: pain, dyspnea…(?) Abdomen: pain, discomfort…(?) Abdomen: pain, discomfort…(?) Limbs and skin : abrasion wound over bil. knee Limbs and skin : abrasion wound over bil. knee

5. AMPLE history Allergies: unknown Allergies: unknown Medication: unknown Medication: unknown Past illness: Past illness: DM:(?) DM:(?) HTN:(?) HTN:(?) Other systemic diseases(?) Other systemic diseases(?) Operation history(?) Operation history(?) Last Meal : (?) Last Meal : (?)

6. Initial evaluation (KMUH) A (airway) / B (breathing): Collar fixation: (+) Collar fixation: (+) Airway: speech: (?) respiration: smooth Airway: speech: (?) respiration: smooth airway obstruction sign (-) airway obstruction sign (-) foreign body in the mouth (-) foreign body in the mouth (-) Trachea Trachea Breathing sound: clear Breathing sound: clear

7. C (circulation): C (circulation): Rate: brachial a., carotid a., femoral a., dorsalis pedis a. Rate: brachial a., carotid a., femoral a., dorsalis pedis a. Cuff BP : 105/45 mmHg Cuff BP : 105/45 mmHg Skin condition: appearance, temperature, humidity Skin condition: appearance, temperature, humidity

8. D (disable): GCS: E2V2M5 GCS: E2V2M5 Pupil response: od: 2 mm os: 2 mm Pupil response: od: 2 mm os: 2 mm E ( exposure ) : abrasion wound over nose and bil. maxillary area, abrasion wound over nose and bil. maxillary area, laceration wound over r’t. upper eyelid(2 cm) and earlobe(1 cm) laceration wound over r’t. upper eyelid(2 cm) and earlobe(1 cm) abrasion wound over bil. knee abrasion wound over bil. knee

9. Secondary evaluation (KMUH ER) Chest X-ray AP & lateral view Chest X-ray AP & lateral view Cervical spine X-ray AP & lateral view Cervical spine X-ray AP & lateral view Pelvis X-ray AP Pelvis X-ray AP Brain CT without contrast ( due to drowsy consciousness and irritable state, brain CT was hold for safety concern ) Brain CT without contrast ( due to drowsy consciousness and irritable state, brain CT was hold for safety concern )

10. Lab data (96/08/20)

12. Chest x-ray

13. Cervical spine X-ray

14. Pelvis X-ray

15. Plan Close observation with plaining brain CT study Close observation with plaining brain CT study

16. At 16:05 Consciousness: coma GCS: E1V1M1 Pupil size: R/L:3.5/2.0 with negative light reflex BP: 150/78 mmHg PR:95/bpm. Consciousness: coma GCS: E1V1M1 Pupil size: R/L:3.5/2.0 with negative light reflex BP: 150/78 mmHg PR:95/bpm. He was sent for emeregnt brain CT He was sent for emeregnt brain CT Emergent endotracheal intubation after Citosol sedation with paralytics (Genso) Emergent endotracheal intubation after Citosol sedation with paralytics (Genso)

18. Tentative diagnosis Traumatic ICH and SDH with mass effect and midline shift Traumatic ICH and SDH with mass effect and midline shift Alcoholism addition Alcoholism addition r/o C- spine injury r/o C- spine injury Left ear lobe laceration (1cm) Left ear lobe laceration (1cm) Facial laceration (2 cm) Facial laceration (2 cm) Abrasion wound over bilateral knees Abrasion wound over bilateral knees

19. Under the impression of traumatic ICH and SDH with mass effect and midline shift, N/S was consult and he was sent to OR for emergent right craniectomy, SDH & ICH removal and ICH monitor insertion. Under the impression of traumatic ICH and SDH with mass effect and midline shift, N/S was consult and he was sent to OR for emergent right craniectomy, SDH & ICH removal and ICH monitor insertion. Then, he was admitted to 7ENI-31 for further therapy. Then, he was admitted to 7ENI-31 for further therapy.

20. Post Operation Post Operation 08/21, GCS:E1 VE M2 ICP was controled during 12~17mmHg, and glycerol was used. 08/21, GCS:E1 VE M2 ICP was controled during 12~17mmHg, and glycerol was used. Fever up to 39 ℃, Sputum (+) were noted. Antibiotics: Cefazolin 1g iv q8h day 2 Fever up to 39 ℃, Sputum (+) were noted. Antibiotics: Cefazolin 1g iv q8h day 2 Gentamicin Gentamicin

21. During 08/22~08/24, spiking fever up to 40 ℃ was noted. During 08/22~08/24, spiking fever up to 40 ℃ was noted. 08/25: The sputum culture collected on 8/22 showed Pseudomonas aeruginosa, and antibiotics shifted to Tazocin 2 vial q8h. 08/25: The sputum culture collected on 8/22 showed Pseudomonas aeruginosa, and antibiotics shifted to Tazocin 2 vial q8h. During 08/26~08/28, persisted mild fever up to 39 ℃ was noted. Follow up brain CT on 8/28: (1) R’t contusion hemorrhage with resolution and During 08/26~08/28, persisted mild fever up to 39 ℃ was noted. Follow up brain CT on 8/28: (1) R’t contusion hemorrhage with resolution and perifocal edema (2) previous left EDH had no enlargement perifocal edema (2) previous left EDH had no enlargement

22. Remove ICP monitor on 08/28 Remove ICP monitor on 08/28 08/29: fever subsided, remove endotracheal tube 08/29: fever subsided, remove endotracheal tube 08/30: Transfer to NS ward 08/30: Transfer to NS ward Q: 無法出 ICU 之併發症 ?

23. Q: 留觀待醒過程是否易 delay diagnosis? Q: 酒後躁動患者是否 sedation 後去做 brain CT?

24. Approach to neuroimaging in children 2007 UpToDate Sedation — Sedation is rarely required for CT examinations in children because most CT examinations take only seconds or minutes to perform, particularly when ultrafast helical/spiral or multidetector/multislice technology is used. Sedation — Sedation is rarely required for CT examinations in children because most CT examinations take only seconds or minutes to perform, particularly when ultrafast helical/spiral or multidetector/multislice technology is used. High-resolution studies that require immobilization to avoid motion artifact (eg, temporal bone examination) are the exception. A newborn or young infant often can be examined during sleep (eg, after a feeding or at the usual nap-time). High-resolution studies that require immobilization to avoid motion artifact (eg, temporal bone examination) are the exception. A newborn or young infant often can be examined during sleep (eg, after a feeding or at the usual nap-time).

25. Hepatic trauma: CT findings and considerations based on our experience in emergency diagnostic imaging European Journal of RadiologyVol: 50 Issue: 1, April, 2004 p: 59-66 In the case of non cooperative patients, presenting with neurological signs, sedation may be required and also assisted ventilation eventually, with continuous monitoring of cardiac and respiratory parameters. In the case of non cooperative patients, presenting with neurological signs, sedation may be required and also assisted ventilation eventually, with continuous monitoring of cardiac and respiratory parameters.

26. Use of Intravenous Methohexital as a Sedative in Pediatric Emergency Departments Hanan Sedik, MD Arch Pediatr Adolesc Med. 2001;155:665-668 Methohexital has been used in adult emergency departments and has been found to produce rapid and brief sedation, especially for orthopedic procedures. Methohexital has been used in adult emergency departments and has been found to produce rapid and brief sedation, especially for orthopedic procedures. Lerman et al studied 76 adult patients in a prospective observational study where IV methohexital had been used for a variety of procedures, and concluded that it caused clinically insignificant changes in hemodynamics and oxygenation. Although respiratory depression did occur, if significant it was brief and easily managed. Lerman et al studied 76 adult patients in a prospective observational study where IV methohexital had been used for a variety of procedures, and concluded that it caused clinically insignificant changes in hemodynamics and oxygenation. Although respiratory depression did occur, if significant it was brief and easily managed. Zink et al reported a consecutive case series of 102 patients (including 10 patients younger than 10 years) who received IV methohexital for various procedures. The authors concluded that methohexital is safe and effective in selected emergency department patients. Zink et al reported a consecutive case series of 102 patients (including 10 patients younger than 10 years) who received IV methohexital for various procedures. The authors concluded that methohexital is safe and effective in selected emergency department patients.

27. Current condition Admission to 7B 27-1 Admission to 7B 27-1 GCS:E2 V2 M3 GCS:E2 V2 M3 BP: 109/78 mmHg BP: 109/78 mmHg Pupil: R 2.5mm L 2.5mm, bilateral prompt reflex Pupil: R 2.5mm L 2.5mm, bilateral prompt reflex MP R L MP R L upper limb 2 1 upper limb 2 1 lower limb 2 2 lower limb 2 2 Plan : Plan : 1. keep Saxizon 100mg iv q8h second day due to bilateral bronchus wheezing 2. Antibiotics: Tazocin 2 vial iv q8h day 9 3. Consult rehabilitation department

28. Thanks for attention~

29. Lerman B, Yoshida D, Levitt MA. A prospective evaluation of the safety and efficacy of methohexital in the emergency department. Am J Emerg Med. 1996;14:351-354. MTX caused clinically insignificant changes in hemodynamics or oxygenation, although respiratory depression did occur; significant respiratory depression was brief and easily managed. MTX provided rapid and excellent levels of sedation with little or no patient recall or pain. MTX caused clinically insignificant changes in hemodynamics or oxygenation, although respiratory depression did occur; significant respiratory depression was brief and easily managed. MTX provided rapid and excellent levels of sedation with little or no patient recall or pain.