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  1. Case Conference 指導老師 李維哲 醫師 Intern 莊淵智 2007.7.3

  2. Patient’s profile • Chart NO. : 10056413 • Name : 王XX • Age : 20y/o • Sex : male • Date of ER visiting : 2007.6.30 (19:32pm)

  3. Condition at Scene • Chief complaint : racing car crash(80km/hr) to the enclosure • Vital sign : HR= 66 bpm, BT= 35.7’C RR= 16/min, BP= 110/70 mmHg • GCS : E4V5M6

  4. Seat-belt mark

  5. Physical examination • Head : nil • Neck : nil • Chest : left side pain, no dyspnea breathing sound: bil. clear • Abdomen : left side pain

  6. Past history • Asthma in childhood • Deny any other systemic diseases

  7. Management (6/30) 19:55 CBC. GOT. GPT. BUN. Cr. Na. K. Sugar. Amylase. Lipase. CK. CK-MB. Troponin-I Chest X-ray, 12-lead EKG N/S 1 BT IVD. Ice package. O2 2L/min. NPO 20:20 Demerol 40mg IM 21:30 N/S 1 BT IVD 22:45 Dacoton (pain-killer) 1# qid x 3 days Sketa (muscle relaxant) 1# qid x 3 days Serenal (Oxazolam) 1# qid x 3 days Strocain 1# qid x 3 days

  8. Management (7/1) 03:20 Constipation  EVAC 1 tube enema 06:35 General weakness  Finger sugar (246). BP= 100/57 mmHg, HR= 125 bpm + lip pale  CBC 07:25 Dyspnea  R/O internal bleeding  Chest and Abdominal CT with contrast  N/S 1 BT 07:40 BP= 98/56 mmHg, HR= 140 bpm 08:10 BP= 96/56 mmHg, HR= 110 bpm

  9. Management (7/1) 08:50 BP= 119/73 mmHg, HR= 109 bpm, GCS=E3V5M6  Check PT. PTT. BP. HR  Consult Radiologist and GS 09:15 IV over  N/S 1 BT + Bain 1 Amp IVD 09:50 BP= 116/67 mmHg, HR= 118 bpm, SpO2= 97% 10:35 NPO, absolute Bed-rest, on Foley 備 PRBC 4u, PLT 12u, FFP 4u 待床SICU 11:40BP= 98/63 mmHg, HR= 127 bpm, recheck血型  Gelofusine 1 BT IVD

  10. Management (7/1) 13:10 BP= 112/69 mmHg, HR= 123bpm  輸PLT 12u 14:05 BP= 117/67 mmHg, HR= 119 bpm, BT= 37.3’C, SpO2= 98%  輸PRBC 2u, 於16:30 繼續輸PRBC 2u 19:50 BP= 121/70 mmHg, HR= 105 bpm  PRBC輸畢, p’t無不適反應  開始輸FFP 4u 21:20 Itchiness + low abdominal and right lower leg rash  Hold FFP (剩NO.3, NO.4 1/2 bag)  Vena-Ca-B6 1 Amp Saxizon (Hydrocortisone) 1/2 vial

  11. Management (7/1-7/2) 22:10 BP= 123/66 mmHg, HR= 96bpm, BT= 37.7’C 22:40 Itchiness subsided  繼續輸剩餘的PRBC 1/2 bag 23:10 BP= 131/64 mmHg, HR= 100 bpm PRBC輸畢, p’t無不適反應 06:00 BP= 143/89 mmHg, HR= 100bpm, BT= 37.4’C  CBC

  12. Management (7/2) 09:00 BP= 159/74 mmHg, HR= 99bpm, Hb= 8.8 mild dyspnea, postural dizziness  Blood transfusion (備whole blood 2u + PRBC 2u) 10:30 Vital sign stable, Breathing sound: bil. clear 10:50 BP= 128/71 mmHg, HR= 89 bpm  Rideron (4mg) 1 Amp + Allecium B6 1 Amp  輸A/+ whole blood 1u 11:50 Taita NO.4 1 BT 12:25 Patient complain dyspnea, SpO2= 98%, RR= 28/min  Saxizon 1/2 vial, O2 2L/min use

  13. Management of TraumaticRetroperitoneal Hematoma Ann Surg. 1990 Feb;211(2):109-23.

  14. Operation ? • based on mechanism of injury + hemodynamic status + extent of associated injuries • Opened • Midline, lateral paraduodenal, lateral pericolonic not associated with pelvic, and portal hematomas are after proximal vascular control has been obtained, if appropriate. • Not opened • Selected retroperitoneal hematomas in the lateral perirenal and pelvic areas • Retrohepatic hematomas without obvious active hemorrhage

  15. Penetrating trauma most still opened  Exceptions : isolated lateral perirenal hematomas that have been carefully staged by CT and some lateral pericolonic hematomas • Blunt trauma without obvious active hemorrhage  not opened

  16. Management of traumatic retroperitoneal hematoma J Chir (Paris). 2004 Jul;141(4):243-9

  17. Traumatic retroperitoneal hematoma (RPH) • Zone 1 (central) : esophageal hiatus to the sacral promontory • Zone 2 (lateral) : lateral diaphragm to the iliac crest • Zone 3 (pelvic) : retroperitoneal space of the pelvic bowel • Surgical exploration  persistent hemodynamic instability, mechanism of injury, location • Urgent surgery upper central area (Zone 1) + penetrating trauma + injury to the great vessels • Evaluation : CT and/or angiography

  18. Thanks for your attention!!

  19. EKG

  20. Chest X-ray Back

  21. Lab Data (6/30, 20:10PM) Back

  22. Lab Data (7/1, 06:39AM) Back

  23. Lab Data (7/1, 08:57AM) Back

  24. Lab Data (7/2, 07:00AM) Back