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Emergency department Case report

Emergency department Case report. Date: 2006.09.14 Intern 韓易庭. Patient profile. Name: 陳雷 X Age: 19y/o Gender: male Chart number: 23119114 Room number: 18ES 55 Admitted time: 95.09.16 PM 20:39. Pre-hospital phase. Transferred from 小港 hospital

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Emergency department Case report

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  1. Emergency department Case report Date: 2006.09.14 Intern 韓易庭

  2. Patient profile • Name: 陳雷X • Age: 19y/o • Gender: male • Chart number: 23119114 • Room number: 18ES 55 • Admitted time: 95.09.16 PM 20:39

  3. Pre-hospital phase • Transferred from 小港 hospital • Event: Hit by iron rod in chest and abdomen while working • Pre-hospital vital signs: unknown • AMPLE: unknown • Trauma evaluation: • Chest and abd blunt injury • Spleen laceration • Left kidney laceration • Left pneumothorax • Left Colles’ fracture • Emergency Treatment: • L/R 1500ml, N/S 100ml, • Aspegic, Transamin, Demerol • Chest CT, Abd CT

  4. Status on arrival PM 20:39 • Conscious: alert • Respiration: 10~24 cpm • Blood pressure: 119/41 mmHg • Pulse rate: 99 bpm • Body temperature: 36 degree • 檢傷分級： 1st degree • Foley:????????

  5. Chief complaint and observation(patient and family) • Dyspnea? chest tightness? • Left wrist pain? • Left abdominal distension? Tnederness? Discomfort?

  6. Obstruction RR, BS BP, PR GCS Deformity Airway Breathing Circulation Disability Exposure Immobilization percussion Skin color Pupil size Echymosis • Primary ABCDE Airway obstruction Open pneumothoraxTensionpneumothorax Flail chestMassive hemothorax Cardiac temponade

  7. Primary ABCDE • Airway • Breathing • Circulation • Disability • Exposure Conscious: alert Respiration: 10~24 cpm Blood pressure: 119/41 mmHg Pulse rate: 99 bpm Body temperature: 36 degree

  8. Initial Management PM 20：53 N/S 1000ml IVD EKG, SpO2 monitor Nasal cannula 4L/min CXR, KUB, Left forearm CBC, PT/PTT, Blood type cross test Consult Uro Consult GS On CVP, left subclavian Abdominal CT SpO2 99%

  9. Image from 小港

  10. Image from 小港

  11. Image from 小港

  12. Image

  13. Image: intravenous urography (IVU)

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  15. Abdominal CT

  16. Lab data 950916 PM 20:53 • 一般血液檢驗 • 檢 體 :Blood • 項 目 : WBC RBC HGB HCT MCV MCH MCHC • 日期(時間) x1000/ul x10^6/ul g/dl % fl Pg g/dl • 950909 29.65 2.59 7.6023.6 91.1 29.3 32.2 • 檢 體 :Blood • 項 目 : PLT RDW-CV RDW-SD • 日期(時間) x1000/ul % fl • 950909 139 13.2 44.3

  17. Lab data 950916 PM 20:53 • PT P:13.1 second • PT C:10.7 second • PT(INR): 1.30 R • PTT P: 26.8 second • PTT C: 29.5 second

  18. Lab data 950916 PM20:53 • Glu(AC): 153 mg/dl • GOT: 46IU/L • GPT: 34IU/L • BUN(B): 15 mg/dl • CRTN(B): 1.43 mg/dl • CK: 256 IU/L • CK-MB: 53 IU/L • Amylase: 49 IU/L

  19. The spleen, 75-150 g, is a highly vascular organ that filters an estimated 10-15% of total blood volume every minute. One kidney 150 cc, One Renal blood flow 600cc Counts for ¼ of cardica output , about 1200cc/min. Problem list Kindey injury scale (Moore 1989) Grade 1 Hematuria with normal imaging studies Contusions Nonexpanding subcapsular hematomas Grade 2 Nonexpanding perinephric hematomas confined to the retroperitoneum Superficial cortical lacerations less than 1 cm in depth without collecting system injury Grade 3 Renal lacerations greater than 1 cm in depth that do not involve the collecting system Grade 4 Renal lacerations extending through the kidney into the collecting system Injuries involving the main renal artery or vein with contained hemorrhage Segmental infarctions without associated lacerations Expanding subcapsular hematomas compressing the kidney Grade 5 Shattered or devascularized kidney Ureteropelvic avulsions Complete laceration or thrombus of the main renal artery or vein • Internal bleeding: spleen and L’t kidney laceration • Pneumothorax • Left Colles’ fracture Spleen injury scale (1994 revision) Grade I Subcapsular hematoma of less than 10% of surface area Capsular tear of less than 1 cm in depth Grade II Subcapsular hematoma of 10-50% of surface area Intraparenchymal hematoma of less than 5 cm in diameter Laceration of 1-3 cm in depth and not involving trabecular vessels Grade III Subcapsular hematoma of greater than 50% of surface area or expanding and ruptured subcapsular or parenchymal hematoma Intraparenchymal hematoma of greater than 5 cm or expanding Laceration of greater than 3 cm in depth or involving trabecular vessels Grade IV Laceration involving segmental or hilar vessels with devascularization of more than 25% of the spleen Grade V Shattered spleen or hilar vascular injury

  20. Secondary ABCDE From Head to Toe Extremities Back and hip Head and Neck Chest Pelvic • Speculation • Palpation • Percussion • Auscultation • Fracture • Distal palpation • Sensation • Range of motion • Split • Laceration wound • Tenderness point • Deformities • Fracture • Speculation • Palpation • Percussion • Auscultation • Fracture • Laceration wound • Laceration wound • Tracheal deviation • Jugular venous engorgement • Subcutaneous emphysema

  21. Time line • PM 21:10 • PRBC 2U • Gelofusine 4% 1BT • N/S 500ml IVD • 烤燈 • PM 21:30 • PM 22:00 • On chest tube 32#  left, keep 10cm • F/U CXR BP：73/30 mmHg PR: 94bpm SpO2: 100% CVP level: 2cm H2O BP：121/61 mmHg PR: 88bpm SpO2: 100% BP：114/71 mmHg PR: 104bpm SpO2: 100%

  22. Image

  23. Time line • PM 22:30 • PRBC 2U  OP • FFP 6U • Pre-Op order • Sign op permit • Sign op schedule • NPO • N/S 500ml • Morphine 5ml IV st BP：137/72 mmHg PR: 102bpm SpO2: 100% BT: 36.3 degree E4V5M6

  24. Assessment • Internal bleeding, • Spleen rupture (Gr II) • L’t kidney rupture (Gr II) • L’t pneumothorax with lung contussion • R’t pneumothorax • L’t radius fracture  Colle’s fracture

  25. References • Emergency Trauma Training Course • ACLS 精華 3rd edition • Sabiston Textbook of Surgery 17 th deition • eMedicine 10/21/2002 • Moore 1989

  26. Thank you for your attention !!!!!!!

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