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Case report

Case report. By 8901002 馮文翰. Identity. Name: 崔 X 誠 Sex: male Age: 29 years old Chart number: 07186872 來急診的時間： 2006.8.11. Chief complaint. Traffic accident on pm10:00, 8/11. Present illness.

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Case report

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  1. Case report By 8901002 馮文翰

  2. Identity • Name:崔X誠 • Sex: male • Age: 29 years old • Chart number: 07186872 • 來急診的時間：2006.8.11

  3. Chief complaint • Traffic accident on pm10:00, 8/11

  4. Present illness • This 29 y/o male was well-being before. Unfortunately, he suffered from a traffic accident on 8/11. The mechanism of the trauma was a car crushing him from his back. His consious was lost since the accident. Then he was brought to 小港Hosptial for help. • On the arrival of 小港H, he was pulseless and GCS showed E1V1M1. The CPR was started and endotracheal tube was inserted there. Then, the resucitation was successful. And he was transferred to our ER after his condition was stable.

  5. The status on arrival • Vital sign：85/42 mmHg, HR= 85/min, RR= 25/min with mechanical ventilator support, BT=36.3oC • Refer from 小港醫院：On Endo, NG, Foley • Coma scale：E1VEM1

  6. Impression 1.frontal SDH 2.left tibial-fibular fx 3.pelvic fx 4.C1-2 fx, C6-7 dislocation 5.R/O internal bleeding Management: Atropine 1 amp Adrenaline 2 amp Pitressive 1 amp Gelofusine 2BT N/S 4 BT 外院的診斷及處理

  7. Initial assessment • A(airway): Endo外on(7.5 Fr, fix 20cm) • B(breathing): 呼吸平順, chest symmetric expansion -->on ventilator: FiO2=100%, RR=16/min, Tidal volumn=560ml • C(circulation): BP=85/42 mmHg, Pulse rate=85 bpm -->N/S 500cc, Gelofusine 1 BT full run • D(defibrillation): no need

  8. Focused history • A: denied • M: denied • P: nil • L: unknown • E: traffic accident

  9. Physical examination • Conscious: E1VeM1 • Pupil: L/R: 2.5mm/2.5mm, with symmetric light reflex • Sclera: not icteric • Neck: supple, LAP(-), JVD(-) • Chest: symmetric expansion BS: bilateral coarse HS: regular heart beat, no murmur • Abdomen: soft, • L/L: no pitting edema • Left elbow abrasion wound, right legs abrasion wound, left lower leg laceration and abrasion

  10. ABG pH=7.258 pCO2=44.6 pO2=370 HCO3=19.5 SaO2=99.9% CBC & electrolyte WBC=11.67 RBC=4.72 Hgb=14.2 MCV=92.4 PLT=291 Na=139 K=4.4 BUN=12.3 CR=1.2 GOT=65 GPT=46 Available Lab data

  11. management • ABG • Abdominal CT -->r/o internal bleeding • C-spine AP + lateral CT • 12 lead EKG • 床頭抬高(30度) • Ice packing • On EKG monitor • NaHCO3 6 amp • PRBC 6 U • Platelet 12 U • N/S 1 BT • Gelofusin 1 BT

  12. Image study

  13. Impression at ER • Suspect neurologic shock with C1-2 fracture, and C6-7 dislocation • Head injury with frontal subdural hematoma • Pelvic fracture • Left tibial and fibular open fracture

  14. Admission to NSICU • PRBC transfusion for acute blood loss (Hgb= 8.1) • Dopamine pump keep 30 ml/hr • IVF: Taita 3 N/S a.a • Closely monitor vital sign, GCS, and hemodynamics • Current antibiotic: Cefazolin + GM

  15. Thank you for your attentions

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