1. Case presentation Intern 8901066 凌永耀

2. Chief Complain Right femoral, tibia and right forearm open fracture due to traffic accident Right femoral, tibia and right forearm open fracture due to traffic accident

3. The status after the traffic accident Car vs Motorcycle. Car vs Motorcycle. Coma with neck collar Coma with neck collar 固定護目位置 : 右上肢，右下肢 固定護目位置 : 右上肢，右下肢 Respiratory Blood pressure Pulse rate Temperature 16/min 112/90 mmHg 167/min 35.4 C Hypovolemic shock( IV??): 1)Heart rate> 140/min 2) 脈搏壓變窄 3)BP down 4)Respiratory rate??(>35/min) 5)Urine output??  on foley

4. AMPLE history Unknown!! Unknown!!

5. ABCD 初步評估 -AB Airway / Breathing: Airway / Breathing: 需頸椎保護 需頸椎保護 氣道阻塞徵象 :Respiratory effort 氣道阻塞徵象 :Respiratory effort 氣道異物 : 痰 + 口水 氣道異物 : 痰 + 口水 氣管正中 氣管正中 Respiratory sound: bilateral decrease Respiratory sound: bilateral decrease Chest X-ray Chest X-ray R/O pneumothroax R/O pneumothroax

6. ABCD 初步評估 -C Circulation (shock?? ) Circulation (shock?? ) Pulse Pulse Right side: pulseless ( fracture limb) Right side: pulseless ( fracture limb) Left side: normal Left side: normal Skin/ mucosa: pale Skin/ mucosa: pale 骨折處持續出血 : directly decompression 骨折處持續出血 : directly decompression Adequate resuscitation: Adequate resuscitation: blood pH=7.4 + U.O.= 0.5~1.0mL/kg.min blood pH=7.4 + U.O.= 0.5~1.0mL/kg.min

7. 輸液 Blood loss: Blood loss: Lower leg: 1 Units (250~ 400 c.c.) Lower leg: 1 Units (250~ 400 c.c.) Femur: 2 units ( 500~800 c.c.) Femur: 2 units ( 500~800 c.c.) Blood loss >750 c.c. Blood loss >750 c.c. Warm IV fluid (large-bore intravenous line) Warm IV fluid (large-bore intravenous line) Crystalloid (N/S, L/R)  L/R 1 BT Crystalloid (N/S, L/R)  L/R 1 BT Colloid Colloid Blood (SBP 140) Blood (SBP 140)

8. ABCD 初步評估 -D Disability ( intracranial or spinal origin??) Disability ( intracranial or spinal origin??) GCS score: E1V1M2  need early intubation GCS score: E1V1M2  need early intubation Pupils: sluggish right =5mm; left =3mm Pupils: sluggish right =5mm; left =3mm Uncal herniation  壓到 E-W nucleus ?? Uncal herniation  壓到 E-W nucleus ??

9. 1)On O2 2)On ECG monitor 3)L/R 1 bot 4)Blood exam 5)Citosol 6 ml iv 6)Citosol 4 ml iv 7)On endo 7.5 Fr. Fix 22 cm 1600 at arrival BP 112/90 1610 BP 102/ 85 1)On ventilator <TV 500ml, RR 16/min, FiO2 100% 2) 領 Whole blood 8U 3) 止血 : Wound treatment with air splint x 2 4)Abdominal echo 1700 BP 80/41 PR 128 1) 輸注 whole blood 4U 2)Citosol push 5 ml 3)On CVP 4)Consult 骨科

10. 1730 BP 80/41 PR 128 1) 輸注 whole blood 4U 2)Cefazoline 1g+ GM 80mg/ 2ml 3)N/S 1000cc 4) 借 4U PRBC 1755 BP104/80 PR 170 SpO2= 100%, CVP=3cmH2O 1) 輸血完畢，無不良 反應 2)L/R 1 BOT 3)Admitted to 7ES22-19 and send to OR at 1810

11. Plans CBC CBC GOT/GPT BUN Cr GOT/GPT BUN Cr Sugar Na K Sugar Na K PT/PTT PT/PTT Ethanol Ethanol ABG ABG Urine routine Urine routine CK CK-MB CK CK-MB Troponin-I Troponin-I Chest: AP Chest: AP Pelvis: AP Pelvis: AP Hand: AP+ R Hand: AP+ R Forearm: AP+ R Forearm: AP+ R Humur: AP+ R Humur: AP+ R Foot: AP+ R Foot: AP+ R Low leg: AP+ R Low leg: AP+ R Femur: AP+ R Femur: AP+ R CT scan CT scan For Brain (without contrast) For Brain (without contrast) For C-spine (without contrast) For C-spine (without contrast)

12. Available laboratory data(0604)

13. Locate the bleeding

14. Echo ( FAST) Lung sliding: + no OPTX Lung sliding: + no OPTX Negative finding for E-FAST Negative finding for E-FAST

15. Radiography- X ray

16. Chest on 0604 1) No active cardiopulmonary disease. 2) Status post insertion of the endotracheal tube

17. Pelvis AP view

18. Right femur AP View Impression ： Comminuted fracture at right middle femoral shaft with displacement. Impression ： Comminuted fracture at right middle femoral shaft with displacement.

19. Right lower leg AP and Lateral Views Impression ： Fractures at right middle tibial and fibular shafts. Impression ： Fractures at right middle tibial and fibular shafts.

20. Right foot lateral View Impression ： Fracture at the Impression ： Fracture at the right 1st metatarsal right 1st metatarsal bone. bone.

21. CT on brain on 0604

47. LeFort I fracture

60. Initial diagnosis at ER 1) Blunt head trauma (brain concussion) 2) Blunt thoracic trauma with BCI( blunt cardiac injury) 3) Multiple fractures (right forearm, right lower limb, and right foot) 4) Facial bone fracture, right IMC maxillary fracture 5) r/o left wrist contusion with fracture

61. Chest x ray on 0605 1) Pneumomediastinum, soft tissue emphysema over bilateral neck and chest wall. 2) Status post insertion of the endotracheal tube, NG tube and bilateral subclavian central lines.

62. CT on 0610 Low density over right cerebral hemisphere Low density over right cerebral hemisphere Ventricular compression: + Ventricular compression: + Mid-line shift: + Mid-line shift: + Impression: acute CVD at right hemisphere favor trauma related( fatty emboli may be considered Impression: acute CVD at right hemisphere favor trauma related( fatty emboli may be considered

81. Thanks a lot!!