急外 Case conference

Intern 黃昱豪

Patient’s Profile

Name: 劉 X 英 Age: 20 years old Gender: Female Chart Number: 22101481 Time of admission: 95-09-08 ,03:11a.m.

Pre-hospital phase

Pre-hospital primary ABCDE

Event: traffic accident (motorcycle, 大順建興 ) Pre-hospital vital signs: 02:59 清 , RR.:22cpm , PR:102bpm, BP:114/86mmHg ,E4V5M6 03:06 清 , RR.:22cpm , PR:100bpm, BP:120/84mmHg ,E4V5M6

Trauma evaluation: left upper extremity deformity Patient’s complaints: dyspnea, pain ,weakness AMPLE history: all denied Pre-hospital Management : Transferred by 119 with upper extremities air splints Psycological support

Emergency department phase

Status on arrival

Time of admission: 95-09-08 ,03:11a.m. 檢傷分級：第 2 級 AVPU:alert RR.:10-24cpm , PR:105bpm, BP:129/80mmHg< 右腳 > BT: 37’C< 耳溫 >

PRIMARY ABCDE –Airway / Breathing

Airway : Intact On neck collar: <?> Breathing ： Resp. rate: 10-24/min Breathing sound ： not recorded Chest percussion: not recorded SpO2: not recorded

PRIMARY ABCDE -Circulation

BP(RL): 129/80 mmHg Pulse: 105 beats/min Pulse assessment: not recorded Skin color assessment: pale<?>,cold<?>

PRIMARY ABCDE -Disability

AVPU: alert GCS score: E4V5M6 Pupil: not recorded

PRIMARY ABCDE -Exposure

left upper arm deformity Severe back pain with radiation to sternum

PRIMARY ABCDE –problems list

1.tachycardia 2.pain 3.left upper arm deformity

Initial Management

Pulse oximetry Medication Keto 1amp im.for pain control IV fluid N/S 1 BT ivd X-ray1.chest PA

2.L’t humeral AP+Lat.

3.L’t forearm AP+Lat Diet NPO

X-Ray <chest AP>

X-Ray <L’t arm>

Initial impression

1.right side hemothorax 2.left humeral fracture 3.tachycardia, r/o hemorrhage related

SECONDARY ABCDE- repeated general survey

1.AMPLE

2.Tubes and fingers in every orifice

3.Head to toe evaluation

The following conditions and managements

03:44BP:126/82 mmHg, HR:111bpm

check CBC , PT/PTT, Na/K,

GOT/GPT, BUN/Cr

check CK, CK-MB, Troponin-I

follow 12-lead EKG

Lab data 檢 體 :Blood 項 目 : WBC RBC HGB HCT MCV MCH MCHC PLT 日期 ( 時間 ) x1000/ul x10^6/ul g/dl % fl Pg g/dl x1000/ul 950908 6.69 3.01 9.2 28.3 94.0 30.6 32.5 175

檢 體 :Blood 項 目 : NA K CK Tropo-I CK-MB BUN CREA AST 日期 m mol/L m mol/L U/L ng/mL U/L mg/dl mg/dl IU/L 950908 138 3.76 1404 0.139 9.7 10.1 0.61 47

項 目 : ALT Ca++ PT p PT c PT(INR) PTT P PTT C 日期 ( 時間 ) IU/L mg% second second R second second 950908 22 4.64 12.6 10.6 1.21 30.6 29.2

12-lead EKG

The following conditions and managements

04:07BP:119/77 mmHg, HR:89bpm 04:40N/S 1BT ivd

arrange chest CT with and without

contrast

Chest CT

The following conditions and managements

05:00BP:112/75 mmHg, HR:105bpm

on chest tube 32Fr, 12cm

on CVP and add N/S 1BT

check CVP level:-3 cmH2O

on Foley

The following conditions and managements

06:00follow chest PA 06:30follow chest PA

The following conditions and managements

06:25add L/R 2BT ivd 06:30 BP:108/71mmHg,PR:119bpm,SpO2:96%

BT: 37.4’C, CVP level:2 cmH2O pull out CVP line to 14cm 07:40 BP:136/86mmHg,PR:127bpm,SpO2:98%

BT: 37.4’C

add N/S 1BT ivd

The following conditions and managements

08:40follow CK, CK-MB, Troponin-I again

follow ABG

consult CVS for r/o cardiac contusion

consult CV for performing bedside

cardiac echo

consult Ortho for left arm fx

Lab data 檢 體 :Blood 項 目 : CK Tropo-I CK-MB 日期 : U/L ng/mL U/L 950908 1404 0.139 9.7 950908 1210 0.146 11.5

檢 體 :Blood 項 目 : pH pCO2 pO2 HCO3 TCO2 BEb SBC BEecf 日期 mmHg mmHg mmol/L mmol/L mmol/L mmol/L mmol/L 950908 7.387 37.5 86.5 22.0 19.2 -2.5 22.3 -3.0

Bedside cardiac echo

The following conditions and managements

09:00 BP:118/76mmHg,PR:91bpm

on long arm splint 10:15 BP:111/71mmHg,PR:80bpm

BT: 38.4’C, CVP level:8 cmH2O

transfer to 15ES-ICU ward

ER Initial diagnosis

1.right chest contusion hemorrhage 2.right hemopneumothorax 3.left humeral fracture 4.sternum fracture

Thanks for your attention!!