Emergency department case report
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Emergency department Case report. Date: 2006.09.14 Intern 韓易庭. Patient profile. Name: 陳雷 X Age: 19y/o Gender: male Chart number: 23119114 Room number: 18ES 55 Admitted time: 95.09.16 PM 20:39. Pre-hospital phase. Transferred from 小港 hospital

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Emergency department Case report

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Emergency department case report

Emergency department Case report

Date: 2006.09.14

Intern 韓易庭


Patient profile

Patient profile

  • Name: 陳雷X

  • Age: 19y/o

  • Gender: male

  • Chart number: 23119114

  • Room number: 18ES 55

  • Admitted time: 95.09.16 PM 20:39


Pre hospital phase

Pre-hospital phase

  • Transferred from 小港 hospital

  • Event: Hit by iron rod in chest and abdomen while working

  • Pre-hospital vital signs: unknown

  • AMPLE: unknown

  • Trauma evaluation:

    • Chest and abd blunt injury

      • Spleen laceration

      • Left kidney laceration

      • Left pneumothorax

      • Left Colles’ fracture

  • Emergency Treatment:

    • L/R 1500ml, N/S 100ml,

    • Aspegic, Transamin, Demerol

    • Chest CT, Abd CT


Status on arrival pm 20 39

Status on arrival PM 20:39

  • Conscious: alert

  • Respiration: 10~24 cpm

  • Blood pressure: 119/41 mmHg

  • Pulse rate: 99 bpm

  • Body temperature: 36 degree

  • 檢傷分級: 1st degree

  • Foley:????????


Chief complaint and observation patient and family

Chief complaint and observation(patient and family)

  • Dyspnea? chest tightness?

  • Left wrist pain?

  • Left abdominal distension? Tnederness? Discomfort?


Emergency department case report

Obstruction

RR, BS

BP, PR

GCS

Deformity

Airway

Breathing

Circulation

Disability

Exposure

Immobilization

percussion

Skin color

Pupil size

Echymosis

  • Primary ABCDE

Airway obstruction

Open pneumothoraxTensionpneumothorax

Flail chestMassive hemothorax

Cardiac temponade


Primary abcde

Primary ABCDE

  • Airway

  • Breathing

  • Circulation

  • Disability

  • Exposure

Conscious: alert

Respiration: 10~24 cpm

Blood pressure: 119/41 mmHg

Pulse rate: 99 bpm

Body temperature: 36 degree


Initial management pm 20 53

Initial Management PM 20:53

N/S 1000ml IVD

EKG, SpO2 monitor

Nasal cannula 4L/min

CXR, KUB, Left forearm

CBC, PT/PTT, Blood type cross test

Consult Uro

Consult GS

On CVP, left subclavian

Abdominal CT

SpO2 99%


Image from

Image from 小港


Image from1

Image from 小港


Image from2

Image from 小港


Image

Image


Image intravenous urography ivu

Image: intravenous urography (IVU)


Image1

Image


Abdominal ct

Abdominal CT


Lab data 950916 pm 20 53

Lab data 950916 PM 20:53

  • 一般血液檢驗

  • 檢 體 :Blood

  • 項 目 : WBC RBC HGB HCT MCV MCH MCHC

  • 日期(時間) x1000/ul x10^6/ul g/dl % fl Pg g/dl

  • 950909 29.65 2.59 7.6023.6 91.1 29.3 32.2

  • 檢 體 :Blood

  • 項 目 : PLT RDW-CV RDW-SD

  • 日期(時間) x1000/ul % fl

  • 950909 139 13.2 44.3


Lab data 950916 pm 20 531

Lab data 950916 PM 20:53

  • PT P:13.1 second

  • PT C:10.7 second

  • PT(INR): 1.30 R

  • PTT P: 26.8 second

  • PTT C: 29.5 second


Lab data 950916 pm20 53

Lab data 950916 PM20:53

  • Glu(AC): 153 mg/dl

  • GOT: 46IU/L

  • GPT: 34IU/L

  • BUN(B): 15 mg/dl

  • CRTN(B): 1.43 mg/dl

  • CK: 256 IU/L

  • CK-MB: 53 IU/L

  • Amylase: 49 IU/L


Problem list

The spleen, 75-150 g, is a highly vascular organ that filters an estimated 10-15% of total blood volume every minute.

One kidney 150 cc, One Renal blood flow 600cc

Counts for ¼ of cardica output , about 1200cc/min.

Problem list

Kindey injury scale (Moore 1989)

Grade 1

Hematuria with normal imaging studies

Contusions

Nonexpanding subcapsular hematomas

Grade 2

Nonexpanding perinephric hematomas confined to the retroperitoneum

Superficial cortical lacerations less than 1 cm in depth without collecting system injury

Grade 3 Renal lacerations greater than 1 cm in depth that do not involve the collecting system

Grade 4

Renal lacerations extending through the kidney into the collecting system

Injuries involving the main renal artery or vein with contained hemorrhage

Segmental infarctions without associated lacerations

Expanding subcapsular hematomas compressing the kidney

Grade 5

Shattered or devascularized kidney

Ureteropelvic avulsions

Complete laceration or thrombus of the main renal artery or vein

  • Internal bleeding: spleen and L’t kidney laceration

  • Pneumothorax

  • Left Colles’ fracture

Spleen injury scale (1994 revision)

Grade I

Subcapsular hematoma of less than 10% of surface area

Capsular tear of less than 1 cm in depth

Grade II

Subcapsular hematoma of 10-50% of surface area

Intraparenchymal hematoma of less than 5 cm in diameter

Laceration of 1-3 cm in depth and not involving trabecular vessels

Grade III

Subcapsular hematoma of greater than 50% of surface area

or expanding and ruptured subcapsular or parenchymal hematoma

Intraparenchymal hematoma of greater than 5 cm or expanding

Laceration of greater than 3 cm in depth or involving trabecular vessels

Grade IV

Laceration involving segmental or hilar vessels with devascularization

of more than 25% of the spleen

Grade V

Shattered spleen or hilar vascular injury


Emergency department case report

  • Secondary ABCDE

From Head to Toe

Extremities

Back and hip

Head and Neck

Chest

Pelvic

  • Speculation

  • Palpation

  • Percussion

  • Auscultation

  • Fracture

  • Distal palpation

  • Sensation

  • Range of motion

  • Split

  • Laceration wound

  • Tenderness point

  • Deformities

  • Fracture

  • Speculation

  • Palpation

  • Percussion

  • Auscultation

  • Fracture

  • Laceration wound

  • Laceration wound

  • Tracheal deviation

  • Jugular venous engorgement

  • Subcutaneous emphysema


Time line

Time line

  • PM 21:10

    • PRBC 2U

    • Gelofusine 4% 1BT

    • N/S 500ml IVD

    • 烤燈

  • PM 21:30

  • PM 22:00

    • On chest tube 32#  left, keep 10cm

    • F/U CXR

BP:73/30 mmHg

PR: 94bpm

SpO2: 100%

CVP level: 2cm H2O

BP:121/61 mmHg

PR: 88bpm

SpO2: 100%

BP:114/71 mmHg

PR: 104bpm

SpO2: 100%


Image2

Image


Time line1

Time line

  • PM 22:30

  • PRBC 2U  OP

  • FFP 6U

  • Pre-Op order

    • Sign op permit

    • Sign op schedule

    • NPO

    • N/S 500ml

    • Morphine 5ml IV st

BP:137/72 mmHg

PR: 102bpm

SpO2: 100%

BT: 36.3 degree

E4V5M6


Assessment

Assessment

  • Internal bleeding,

    • Spleen rupture (Gr II)

    • L’t kidney rupture (Gr II)

  • L’t pneumothorax with lung contussion

  • R’t pneumothorax

  • L’t radius fracture  Colle’s fracture


References

References

  • Emergency Trauma Training Course

  • ACLS 精華 3rd edition

  • Sabiston Textbook of Surgery 17 th deition

  • eMedicine 10/21/2002

  • Moore 1989


Emergency department case report

Thank you for your attention !!!!!!!


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