case presentation presenter : 8901157 intern 黃曉禹
TRANSCRIPT
Case Presentation
Presenter : 8901157 Intern 黃曉禹
Brief History referred from 小港 Male 54y/o 07431690 Conscious : clear??,
E4V5M5 1200 TA
close pelvic fracture 左前胸 , 左臉 , 左手 ,
左腳 開放性傷口紗布
小港 6600 cc fluid 1 2-way CVP line
1. PRBC 1U 2. Gelofusin 1 BT
2 peripheral line right hand IV with N/
S right foot iv with N/S
1st assessment (950817 1438) Airway:
patent no need neck protect Can talk
Breathing:10-24 obstruction: nil foreign:nil tracheal deviation: ni
l
Circulation :74/40 skin: pale temperature warm moist : normal Pulse:normal Bleeding : ??
Disability : E3V5M6 GCS=14
Expose / Enviroment
2nd assessment Allergy : nil Medication : 胃藥 Past illness: 胃痛 Last meal : 950817 1200 Events : Traffic accident, crushing injury
小港 H suggest angiography & embolization
General survey : Left ant face , chest, left upper limbs & lower limb
s open wound, no active bleeding
Initial management 1440
O2 4L/min blood exam n/s 1000ml ivd on EKG monitor On oxymeter 備血
PRBC 6U FFP 6U PLT 12U
1457 arrange angiography, sign permit
1440 SaO2 94%
1500 BP 95/50 p90 N/S 1 BT
1515 BP 84/38, p88 Send angio room
Pelvic fracture Force?
前後 -pelvic unstable + threatening hypotension
側面 - bladder & ureter injury
垂直 - pelvic unstable Volume status
6600cc in about < 3hr Hypovolemic status Fluid resuscitation
3:1 crystaloid : blood loss
Crushing injury>3:1(more crystaloid)
Progressive bleeding <3:1 (more blood)
小港 lab data WBC 6280/ul RBC 5.2 HGB 15.4 HCT 45.9 PLT 184 PT P/PT C= 11.9 /
10.7 PTT P/ PTT C =
28.7 / 1.65
GOT/GPT 31/29 BUN/CREA
22.8/1.65 NA/K=137/3.8 GLU 245
1440 blood exam Distal upper
limb 150-250 Proximal
upper limb 250
Distal lower limb 500
Proximal lower limb 1000
Pelvic 1500-3000
小港 CT
Angiography & embolization
angiography
The aortogram, bilateral internal iliac arteriography reveal extravasation via the left superior gluteal artery.
2nd management --back from angio room -- continue bleeding 1720 consult OW
whole blood 10 U 1740
BP 112/78 P102 PRBC 2U 無不適 DOPAMINE 2 amp + N/S 1 BT keep 10 gtt/min
1810 P RBC *2 BP121/76 P102 FFP 2U * 2 P RBC * 2
1850 N/S 1BT + transamine 1 amp
1905 BP 109/72 P103 Sao2 100%
2nd management --back from angio room -- continue bleeding 1910
sign permit NPO N/S 1 Bt + trasamine 2amp IVD
chest-x-ray PA view 1930 BP: 107/59 PR 101 2010 BP: 99/59 P102
2035 BP 98/53 P120 SaO2:100%
2040 blood exam ABD CT enhanced
2050 sent p't to CT room 95/50 P128 Sao2 100%
Source of bleeding ?? Open wound
左前胸 左臉 左手 左腳
Image 2
Chest x-ray Abdomen CT CBC
3th management -- prepare to OR 2110
BP 120/55 P130 SaO2 100% PLT 輸畢無不適
2112 sinus tachycardia
2115 whole blood consult GS
2130: 97/62 P68 Sao2 100% non-rebreathing mask
use 10 L/min
3th management -- prepare to OR 2135
s: dyspnea Sao2 100% On endo
citosol + aq dest1amp-->5u iv
on endo fix 23cm PRN surgeon on ventilator TV 600ml ra
te 8 times/min 2142
EKG sinus tachycardia 2200
BP:104/69 PR118 whole Blood
2215 BP101/69 PR138 sent to OR & 15ESI 1-8
On endo
OR
splenectomy
Impression
Pelvic fracture Hypovolemic shock Spleen laceration Left Kidney parechyma injury Mixed type acidosis, metabolic acidos
is + respiratory acidosis
Thanks for your attention