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急外 Case conference

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:

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急外 Case conference

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  1. 急外 Case conference Intern 黃昱豪

  2. 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.

  3. Pre-hospital phase

  4. 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

  5. Emergency department phase

  6. 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>

  7. 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

  8. PRIMARY ABCDE -Circulation • BP(RL): 129/80 mmHg • Pulse: 105 beats/min • Pulse assessment: not recorded • Skin color assessment: pale<?>,cold<?>

  9. PRIMARY ABCDE -Disability • AVPU: alert • GCS score: E4V5M6 • Pupil: not recorded

  10. PRIMARY ABCDE -Exposure • left upper arm deformity • Severe back pain with radiation to sternum

  11. PRIMARY ABCDE –problems list • 1.tachycardia • 2.pain • 3.left upper arm deformity

  12. Initial Management • Pulse oximetry • Medication Keto 1amp im.for pain control • IV fluid N/S 1 BT ivd • X-ray1.chest PA 2.L’t humeral AP+Lat. 3.L’t forearm AP+Lat • Diet NPO

  13. X-Ray <chest AP>

  14. X-Ray <L’t arm>

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

  16. SECONDARY ABCDE- repeated general survey 1.AMPLE 2.Tubes and fingers in every orifice 3.Head to toe evaluation

  17. The following conditions and managements • 03:44BP: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

  18. 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 9.228.3 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 14040.1399.7 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

  19. 12-lead EKG

  20. The following conditions and managements • 04:07BP:119/77 mmHg, HR:89bpm • 04:40N/S 1BT ivd arrange chest CT with and without contrast

  21. Chest CT

  22. The following conditions and managements • 05:00BP:112/75 mmHg, HR:105bpm on chest tube 32Fr, 12cm on CVP and add N/S 1BT check CVP level:-3 cmH2O on Foley

  23. 06:00follow chest PA 06:30follow chest PA The following conditions and managements

  24. The following conditions and managements • 06:25add 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

  25. The following conditions and managements • 08:40follow 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

  26. 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

  27. Bedside cardiac echo

  28. 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

  29. ER Initial diagnosis • 1.right chest contusion hemorrhage • 2.right hemopneumothorax • 3.left humeral fracture • 4.sternum fracture

  30. Thanks for your attention!!

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