急外 Case Report
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急外 Case Report
Intern 洪毓棋
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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
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Pre-hospital assement
Incident: Falling down from 13 floors Brought by 119 with neck collar and pelvic & l
ower 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
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Airway / Breathing
Neck collar Obstruction: grunting, resp. effort Foreign body: sputum, blood No trachea deviation Bil. Breathing sound clear Resp. rate: 10-24/min SpO2: 94
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Circulation
BP(RA): 57/37 mmHg Pulse: 47/min Pulse assessment: not recorded 皮膚 : 蒼白、冷 (35℃)、乾燥
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Disability
GCS score: E3V3M3(119 record) Pupil: sluggish, 1.5mm/1.5mm
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Lesion appearance
Mandible open fx, 8cm Ant. Chest ecchymosis Left pelvic protrusion Bil. lower leg bone protrusion
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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), cervic
al spine
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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 hemoperi
toneum. Contusion injury ( Hematoma,bullos formation) in bo
th 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 o
ver the anterolateral aspect of left proximal thigh with superior extension.
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FAST
Fluid accumulation Subhepatic Splenic fossa Pelvic cavity
R/O right pneumothorax
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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
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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, SpO2: 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: NaHCO3
16:55: 84/20 mmHg, 117/min 17:00: 93/33 mmHg, 135/min, E1VTM1
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Lab
WBC: 3.77 Sugar: 239 Amylase: 291 PH: 6.908
RBC: 3.81 Urea N: 14.5 Lipase: 308 pCO2: 82.5
Hgb: 11.1 Creatinine: 0.96 PT: 17.3/10.6 PO2: 51.4
Hct: 34.7 NA: 137 PT INR: 2.13 HCO3: 16.1
MCV: 91.1 K: 3.93 PTT: 55.6/30.2 BE: -18.2
MCH: 29.1 GOT: 1336 %sO2: 52.8
MCHC: 32.0 GPT: 1000
PLT: 205
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Anethesia record
BP: 93/33 mmHg Temp: 35℃ PR: 126/min RR: 18/min Intra-operative event: A-line failure, 四肢 cya
nosis, ET suction fresh blood, vital sign 量不到
CRP begin at 17:45, end at 18:34
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Anethesia record-medication
OP start Levophed (1 Amp +D5W 250ml)keep 10 ml/hr NaHCO3 3 Amp Atropine 1 Amp Bosmin 1 Amp NaHCO3 3 Amp
CRP start Bosmin 1 Amp Bosmin 1.5 Amp
Total IV: PRBC 2u, FFP 6u, 2800ml Output: 1500ml by suction
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OP record Under ETGA, massive bleeding at l’t traumatic pelvi
c Incision line at median abd. Massive blood with blood clot was noted after opene
d 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 spl
enic a. and vein.
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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