case conference intern 陳姝蓉. patient profile name: 鍾高 o 錦 79 year-old female occupation:...

Case Conference

Intern 陳姝蓉

Patient profile

Name: 鍾高 O 錦 79 year-old female Occupation: unknown Chart number: 15790607 Arrival time: 2007.04.05 AM08:38 Arrival method: EMT from 小港 hospital

Injury mechanism

The patient ingested unknown amount of hydrochloric acid at 6AM of April 5th

She was brought to 小港 hospital ER for help

Pre-hospital evaluation and management

Sent to 小港 hospital ER Consciousness: drowsy, GCS: E2V2M4-5

Head : ILOC(-), dizziness(-), headache(-), nausea/vomiting(-), amnesia(-), vertigo(-)

Mouth: oral ulcers (+) Neck: pain(-), stiff(-), soreness(-) Chest: pain(-), tachycardia(+) Abdomen: distension(+), tenderness(+) Extremities : edema(+)

Initial evaluation ( 小港 hospital)A (airway) / B (breathing):

Speech: incomprehensible sound Respiration: SaO2: 88% Lips: cyanotic and pale Respiratory rate: 10~24/min

C (circulation): Pulse: palpable over all major peripheral arteries Cuff BP : 122/80 mmHg Skin condition:

Appearance: pale and cyanotic over lips and mouth Temperature: 35.7 C Humidity: unknown

D (disability): GCS: E2V2M4-5

Pupil response:

od: 3mm, +/+ os: 3mm, +/+

E (exposure) : nil

Initial evaluation ( 小港 hospital)

Progression at 小港 hospital Air hunger was noted with deterioration in GCS

(E1V1M1) Intubation with size 7.5 endotracheal tube fixed at 21

cm On ventilator (TV: 500mL, RR: 16/min, FiO2: 100%) On neck CVC and give N/S 1 bottle

Blood pressure dropped to 81/57 mmHg IV full-run Consult surgeon

Due to peritonism, the patient was transferred to KMUH by ambulance

Initial evaluation (KMUH)A (airway) / B (breathing): Collar fixation: (-) Breathing:

Respiratory rate: on endo Airway:

Speech: incapableRespiration: ambu-baggingAirway obstruction sign: presentForeign body in the mouth: absentTrachea: midline

C (circulation): Pulse: impalpable on carotid artery Cuff BP : unmeasurable Skin condition:

Appearance: pale-looking Temperature: cold (34.8C)Humidity: unknown

Initial evaluation (KMUH)

D (disability): GCS: E1VtM1 Pupil response: absent bilaterally

E (exposure) : nil

Initial evaluation (KMUH)

Current medication Unknown

Past history DM: (-), HTN: (+), Hepatitis: (-) Major depressive disorder? Smoking(-), alcohol(-), betal nut(-) Operation history: unknown Allergy history(-) Travel history(-), contact history(-)

Family history Not contributory

Secondary evaluation (KMUH ER)

ECG monitor Lab data Pulse oximeter

Initial management Start CPR Fluid and drugs during resuscitation

NaHCO3 Atropine Adrenaline Gelofusine

Lab CBC, WBC classification, ABG, image

Special management DC shock Ventilator

Lab data

Blood 96/04/05

WBC 12.62 x 103/uL

RBC 1.09 x 106/uL

Hgb 3.5 g/dL

Hct 10.5 %

MCV 96.3 fL

PLT 45 x 103/uL

Neu 66.9 %

Eosin 0.5 %

Baso 0.2 %

Lymph 30.7 %

Mono 1.7 %

Arterial Blood Gas 96/04/05

Temperature 37.0 ℃

pH 7.207

pCO2 24.5 mmHg

pO2 390.8 mmHg

HCO3- 9.5 mmol/L

Total CO2 8.6 mmol/L

Base excess -16.5 mmol/L

SBC 11.9 mmol/L

BEecf -18.4 mmol/L

%sO2c 99.9 %

Image study

Impression Pulseless electrical activity (PEA) on arrival Corrosive esophagogastritis

Plans ACLS

Thanks for your attention !!!

Indication of surgical intervention for corrosive esophagogastritis Clinical signs of perforation, mediastinitis,

or peritonitis