1. Case presentation Intern 陳嘉夆 2006-7-25

2. Personal Profile Name: 徐 X 祺 Age: 22 years old Gender: male Arrival date: 2006-07-07 19:40 referred from 婦幼 Hospital.

3. Status on arrival Conscious : clear, E4V5M6 vital signs : Temperature: 37.2 ℃ Pulse: 93 bpm Respiratory rate: 18 cpm Blood pressure: 147 / 90 mmHg appearance: Bandage on right arm

4. Brief History Chief complaint Right upper limb severe pain and weakness after traffic accident at 6:00 PM. Traumatic history When the patient was ridding on a motorcycle, he collided with a trunk. Patient fell down, and the motorcycle wheel crushed on his right upper limb. helmet(+), ILOC(-), headache(-), N/V(-) Past history : Hearing impairment since childhood. DM(-), HTN(-), allergy(-), current medication(-).

5. Primary ABCDE and management Airway: patent Breathing: tachypnea Circulation: pale skin, cold. Right hand nail bed refilling (+) Disability: GCS:15, no pupil dilatation, light reflex (+) Movement of right hand ↓ ExposureExposure: N/S 1 bot.O 2 2 L/mincompression and fixation

6. exposure Avulsion, (10~20 cm) with peripheral abrasion, Soft tissue loss

7. Impression Massive soft tissue loss with vascular injury of right upper limb.

8. Secondary survey Conscious: clear Vital signs: T/P/R/Bp: 37.2 ℃ / 73bpm/ 18cpm/ 123/79mmHg ABCDE: Lab data survey CBC, BUN, creatinine, Na, K, Cl, PT,PTT, urine routine. Image suvey Chest X ray, forearm, and humeral bone. Arteriography of right upper limb.

9. 19:40 Arrival on KMUH ER - conscious clear, vital signs stable - O2, IV fluid was supplied. - X ray: chest, forearm, humeral.chestforearmhumeral - lab data surveylab data survey - medication: unasyn 2 vial, demerol 50 mg. and tetanus. 7/7 18:11 Traffic accident occurred, then sent to 婦幼 H. 20:40 Morphine 5mg 20:50 Arrange arteriographpy of right arm.arteriographpy 22:30 Consult plastic for emergent vascular construction. 23:40 Admitted to plastic ward.

10. Tentative diagnosis Right elbow crush injury, with right brachial a. disruption and open fracture. Traumatic tattoo Plan Supportive care. Referred to plastic ward for further management.

11. Lab data WBC11610 /ul RBC4.86*10 6 /ul Hgb14.0 g/dl Hct41.1 % MCV84.6 fl MCHC34.1 pg PLT226000/ul RDW-CV 12.3 RDW-SD 37.8 Sugar214 BUN13.9 Creatinine0.86 GOT24 IU/L GPT15 IU/L PT P/C12.1/10.6 s PTT P/C27.3/28.8 s Na137 mmol/L K3.59mmol/L Cl108 mmol/L CPK228 U/L ColorYellow Appearance Clear PH6.0 Sugar1+ RBC0-2 WBC0-2 Epith0-2 SG1.019 CBCbiochemistryUrine routine back