Case Conference

指導老師 李維哲 醫師Intern 莊淵智

2007.7.3

Patient’s profile

• Chart NO. : 10056413

• Name : 王 XX

• Age : 20 y/o

• Sex : male

• Date of ER visiting : 2007.6.30 (19:32pm)

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

Seat-belt mark

Physical examination

• Head : nil

• Neck : nil

• Chest : left side pain, no dyspnea

breathing sound: bil. clear

• Abdomen : left side pain

Past history

• Asthma in childhood

• Deny any other systemic diseases

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

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

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 SICU11:40 BP= 98/63 mmHg, HR= 127 bpm, recheck 血型 Gelofusine 1 BT IVD

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 2u19:50 BP= 121/70 mmHg, HR= 105 bpm PRBC 輸畢 , p’t 無不適反應 開始輸 FFP 4u21:20 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

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

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

Management of TraumaticRetroperitoneal Hematoma

Ann Surg. 1990 Feb;211(2):109-23.

• 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

• 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

Management of traumatic retroperitoneal hematoma

J Chir (Paris). 2004 Jul;141(4):243-9

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

Thanks for your attention!!

EKG

Chest X-ray

Back

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

WBC (103/ul) 17.16 Amylase (U/L) 55

RBC (106/ul) 4.87 Lipase (U/L) 19

Hb (g/dl) 15.0 BUN / Cr(mg/dl) 12.6/0.8

HCT ( ％ ) 43.2 Na (mmol/L) 140

MCV (fl) 88.7 K (mmol/L) 4.6

PLT (103/ul) 150 CPK (U/L) 277

Sugar (mg/dl) 152 CK-MB (U/L) 7.1

GOT / GPT (IU/L) 27/29 Troponin-I (ng/ml)

0.01

Back

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

WBC (103/ul) 24.72

RBC (106/ul) 3.63

Hb (g/dl) 10.8

HCT ( ％ ) 32.4

MCV (fl) 89.3

PLT (103/ul) 207

Back

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

PT (p) 12.0

PT (c) 10.9

INR 1.25

PTT (p) 25.4

PTT (c) 28.6

Back

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

WBC (103/ul) 13.02

RBC (106/ul) 2.92

Hb (g/dl) 8.8

HCT ( ％ ) 25.1

MCV (fl) 86.0

PLT (103/ul) 126

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