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急外 Case Report

急外 Case Report. Intern 洪毓棋. 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. Pre-hospital assement. Incident: Falling down from 13 floors Brought by 119 with neck collar and pelvic & lower extremities air splints 現場生命現象 : response to pain

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急外 Case Report

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  1. 急外 Case Report Intern 洪毓棋

  2. 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

  3. Pre-hospital assement • Incident: Falling down from 13 floors • Brought by 119 with neck collar and pelvic & lower 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

  4. 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

  5. Circulation • BP(RA): 57/37 mmHg • Pulse: 47/min • Pulse assessment: not recorded • 皮膚: 蒼白、冷(35℃)、乾燥

  6. Disability • GCS score: E3V3M3(119 record) • Pupil: sluggish, 1.5mm/1.5mm

  7. Lesion appearance • Mandible open fx, 8cm • Ant. Chest ecchymosis • Left pelvic protrusion • Bil. lower leg bone protrusion

  8. 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), cervical spine

  9. 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 hemoperitoneum. • Contusion injury ( Hematoma,bullos formation) in both 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 over the anterolateral aspect of left proximal thigh with superior extension.

  10. FAST • Fluid accumulation • Subhepatic • Splenic fossa • Pelvic cavity • R/O right pneumothorax

  11. 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

  12. 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

  13. Lab

  14. Anethesia record • BP: 93/33 mmHg • Temp: 35℃ • PR: 126/min • RR: 18/min • Intra-operative event: A-line failure, 四肢cyanosis, ET suction fresh blood, vital sign 量不到 • CRP begin at 17:45, end at 18:34

  15. 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

  16. OP record • Under ETGA, massive bleeding at l’t traumatic pelvic • Incision line at median abd. • Massive blood with blood clot was noted after opened 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 splenic a. and vein.

  17. 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

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