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 & l

ower 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

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

Circulation

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

Disability

GCS score: E3V3M3(119 record) Pupil: sluggish, 1.5mm/1.5mm

Lesion appearance

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

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), cervic

al spine

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 hemoperi

toneum. Contusion injury ( Hematoma,bullos formation) in bo

th 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 o

ver the anterolateral aspect of left proximal thigh with superior extension.

FAST

Fluid accumulation Subhepatic Splenic fossa Pelvic cavity

R/O right pneumothorax

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

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

Lab

WBC: 3.77 Sugar: 239 Amylase: 291 PH: 6.908

RBC: 3.81 Urea N: 14.5 Lipase: 308 pCO2: 82.5

Hgb: 11.1 Creatinine: 0.96 PT: 17.3/10.6 PO2: 51.4

Hct: 34.7 NA: 137 PT INR: 2.13 HCO3: 16.1

MCV: 91.1 K: 3.93 PTT: 55.6/30.2 BE: -18.2

MCH: 29.1 GOT: 1336 %sO2: 52.8

MCHC: 32.0 GPT: 1000

PLT: 205

Anethesia record

BP: 93/33 mmHg Temp: 35℃ PR: 126/min RR: 18/min Intra-operative event: A-line failure, 四肢 cya

nosis, ET suction fresh blood, vital sign 量不到

CRP begin at 17:45, end at 18:34

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

OP record Under ETGA, massive bleeding at l’t traumatic pelvi

c Incision line at median abd. Massive blood with blood clot was noted after opene

d 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 spl

enic a. and vein.

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