1. 急外 Case Report Intern 洪毓棋

2. Patient 姓名 : 黃 X 偕 性別 : 男生 年齡 : 11 歲 ID: 19954221 就診日期 : 95/6/28 下午 2 時 體重 : 28kg

3. Pre-hospital assement Incident: Falling down from 13 floors Brought by 119 with neck collar and pelvic & lower extremities air splints 現場生命現象 : response to pain Head: ILOC: ?, Dizzy Chest and Abd. pain GCS score: E3V3M3 AMPLE history: all denied

4. Airway / Breathing Neck collar Obstruction: grunting, resp. effort Foreign body: sputum, blood No trachea deviation Bil. Breathing sound clear Resp. rate: 10-24/min SpO 2 : 94

5. Circulation BP(RA): 57/37 mmHg Pulse: 47/min Pulse assessment: not recorded 皮膚 : 蒼白、冷 (35 ℃ ) 、乾燥

6. Disability GCS score: E3V3M3(119 record) Pupil: sluggish, 1.5mm/1.5mm

7. Lesion appearance Mandible open fx, 8cm Ant. Chest ecchymosis Left pelvic protrusion Bil. lower leg bone protrusion

11. Management Pulse oximetry, Intubation EKG, CVP N/S and L/R IVD CBC…lab data Medication: Citosol, Demerol, Cefazolin… Chest, bil. lower leg, l’t femur X-ray CT: brain to pelvic (abd. with contrast), cervical spine

17. Image finding No definite evidence of intracranial hemorrhage. Fracture at the left mandibular body. S/P insertion of endotracheal tube. Liver laceration and spleen laceration with hemoperitoneum. Contusion injury ( Hematoma,bullos formation) in both lungs,especially lower lobes. Small amount of pneumothorax in left pleural space. R/O left renal infarction (upper pole). Fracture of left iliac wing and left proximal femur. Soft tissue swelling with subcutaneus emphysema over the anterolateral aspect of left proximal thigh with superior extension.

18. FAST Fluid accumulation Subhepatic Splenic fossa Pelvic cavity R/O right pneumothorax

19. Initial diagnosis Chest contusion, lung contusion Blunt abd. Trauma, liver contusion/laceration Hemoperitoneum with spleen rupture Mandible open fx L’t femur open fx Bil. Lower leg open fx

20. Hemodynamic 14:22 ： 57/37 mmHg, 47/min N/S*3, L/R*1 15:30 ： 83/32 mmHg, 141/min 15:40 ： 78/41 mmHg, 153/min, SpO 2 : 98 Gelofusine 1BT at 16:00 16:30 ： 75/54 mmHg, 154/min Gelofusin 1BT 16:39 ： 100/32 mmHg, 129/min PRBC 6u, FFP 6u Venous gas: NaHCO 3 16:55 ： 84/20 mmHg, 117/min 17:00 ： 93/33 mmHg, 135/min, E1VTM1

21. Lab WBC: 3.77Sugar: 239Amylase: 291PH: 6.908 RBC: 3.81Urea N: 14.5Lipase: 308pCO 2 : 82.5 Hgb: 11.1Creatinine: 0.96PT: 17.3/10.6PO 2 : 51.4 Hct: 34.7NA: 137PT INR: 2.13HCO 3 : 16.1 MCV: 91.1K: 3.93PTT: 55.6/30.2BE: -18.2 MCH: 29.1GOT: 1336%sO 2 : 52.8 MCHC: 32.0GPT: 1000 PLT: 205

22. Anethesia record BP: 93/33 mmHg Temp: 35 ℃ PR: 126/min RR: 18/min Intra-operative event: A-line failure, 四肢 cyanosis, ET suction fresh blood, vital sign 量 不到 CRP begin at 17:45, end at 18:34

23. Anethesia record-medication OP start Levophed (1 Amp +D5W 250ml)keep 10 ml/hr NaHCO 3 3 Amp Atropine 1 Amp Bosmin 1 Amp NaHCO 3 3 Amp CRP start Bosmin 1 Amp Bosmin 1.5 Amp Total IV: PRBC 2u, FFP 6u, 2800ml Output: 1500ml by suction

24. OP record Under ETGA, massive bleeding at l’t traumatic pelvic Incision line at median abd. Massive blood with blood clot was noted after opened peritoneum.(pancreatic tail contusion, liver laceration) T-colon contusion, mesenteric contusion, retroperitoneum massive bleeding was noted Spleen laseration with bleeding was noted. The splenectomy was performed after ligation of splenic a. and vein.

25. OP record Massive retroperitoneum bleeding was still noted. The gauze compression to retroperitoneum(L’t) was performed The unstable vital sign was told by anethesiologist The CPR was started since 17:45 The failure of CPR was noted at 18:34 Wound closure Previous traumatic wound was closure