1 / 27

Journal reading

Journal reading. 急診醫師 陳莉瑋. Basic data and triage. Age:5 y/o Male 檢傷級數 :3 檢傷主訴 : 頭部撕裂傷 , 經壓迫可止血. T/P/R: 36.1/80/24 SBP/DBP: -/- E4V5M6 Body weight:16Kg. Present illness. He suffered from traffic accident on 3/23 with right occipital laceration hurt by his mother’s teeth

elam
Download Presentation

Journal reading

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Journal reading 急診醫師 陳莉瑋

  2. Basic data and triage Age:5 y/o Male 檢傷級數:3 檢傷主訴:頭部撕裂傷,經壓迫可止血 • T/P/R: 36.1/80/24 • SBP/DBP: -/- • E4V5M6 • Body weight:16Kg

  3. Present illness • He suffered from traffic accident on 3/23 with right occipital laceration hurt by his mother’s teeth • There was no discomfort, vomiting, seizure, nor ILOC at that time. • Mechanism： • Past history:nil • Allergy:NKA

  4. Physical examination Conscious clear ,E4V5M6 HEENT: grossly normal except 3cm laceration over right side occipital area Neck: no tenderness ,no LAP Chest: BS clear, RHB, no heart murmur Abdomen: soft, no tenderness Ext: freely movable, no open wound

  5. After three weeks laterhe was took to our ER 檢傷紀錄 Date: 2008/04/09 T/P/R: 38.1/88/24 SBP/DBP: -/- E4V5M6 體重：16 SPO2：98 病患來診為局部性腫脹/發紅，局部性蜂窩性組織炎

  6. Present illness Intermittent fever and headache since 3 days ago, and pus over prior occipital wound s/p suture was noted. The headache was more severe in the morning. There was no nausea, vomiting, diarrhea nor double vision.

  7. Physical examination • T:38.5/℃ P:80/min R:20/min BP:98/51 mmHg • General Appearance: lethargy • Consciousness: clear, E4 V5 M6 • HEENT: • Sclera: anicterus • Conjunctiva: not injected • Pus discharge over occipital wound s/p suture • Lips: no cyanosis • NECK: • supple, no lymphadenopathy • CHEST: • Breath pattern: smooth, bilateral symmetric expansion

  8. Neurological examination Cranial nerves: no focal sign Muscle power: 5/5 DTR :++/++ Babinski sign: plantar flexion/plantar flexion Brudzinski sign: negative; Kernig sign: negative

  9. Lab data WBC          23.3   1000/uL RBC         4.44  million/uL Hemoglobin   11.1   g/dL Hematocrit   34.0 % MCV         76.6   fL MCH          25.0 pg/Cell MCHC         32.6   g/dL RDW         12.6   % Platelets     578  1000/uL Segment      90.0   % Lymphocyte    4.0   % Monocyte      6.0  %   BUN (B)         8      mg/dL Creatinine(B) 0.5      mg/dL AST (GOT)      24      U/L ALT/GPT       12      U/L Na            141      meq/L K             4.2      meq/L CRP         44.28      mg/L Sugar 急診沒有驗 PH          7.315 PCO2         44.9     mmHG PO2         182.2      mmHG HCO3         22.3      mm/L SAT          99.1      %

  10. 2008-04-09 Brain CT

  11. 2008-04-09 Brain CT

  12. NS consult sheet Impression: right side occipital skull depress fracture with focal brain abscess formation with mild midline shift to left side Admission and empiric antibiotic use (Vancomycin + Ceftriaxone + Metronidazole)and mannitol use

  13. This case… 5 Y/O boy with delay brain abscess related with prior undiagnosed occipital skull open fracture Come to ER due to fever and headache three weeks later During admission, he receive partial cranioectomy two times and intravenous antibiotics use

  14. 小兒科醫師注重的是delay brain abscess 不尋常的機制 而我們急診醫師 應該注意的是 how to early diagnosis!

  15. 叔叔 我撞到頭了 醫生 腦有沒有傷到 要不要照個電光 或是電腦斷層 會不會有後遺症？要注意什麼？ 天天上演！

  16. 問題1Are image study necessary in approaching acute head trauma children?

  17. Table

  18. Diagnostic testing for acute head injury in children: when are head computed tomography and skull radiographs indicated? • 321 children , prospective; mechanism of injury, symptom, CT, skull view, PE recorded • Amazing result: • Sixteen (6%) of the 266normal children had intracranial injuries • Depressed skull fracture 4/linear fracture without intracranial injury26 • 6/16:<1歲 Pediatrics 1997;99;e11

  19. 和intra-cranial injury比較有相關的factor • Skull fracture • signs of a basilar skull fracture • loss of consciousness for more than 5 minutes, • altered mental status • focal neurologic abnormality Pediatrics 1997;99;e11

  20. Intracranial injury may also occur with few or subtle signs and symptoms, especially in infants younger than 1year. 一歲以下更要注意 • CT scans should be considered in children with symptomssuch as vomiting, headache, drowsiness, amnesia, and a history of loss of consciousness, even in the absence of the independent predictors of intracranial injury we identified. Pediatrics 1997;99;e11

  21. Journal of Pediatric SurgeryVolume 42, Issue 5, May 2007, Pages 849-852

  22. 問題2 Which image is more useful? Skull film? CT? MRI?

  23. Diagnostic tools • Skull radiographs can be used to identify and classify skull fractures • CTis the preferred modality to identify skull fractures and intracranial injuries • MRI has notbeen shown to provide any advantage over CT in the acute imaging of head trauma uptodate

  24. Patients who are at high risk for intracranial injury are candidates for CT scanning, and plain radiography is of no added value • Skull radiographs may be indicated when the history of trauma is uncertain (eg, skeletal survey in the evaluation of suspected abuse), or to rule out the presence of a foreign body uptodate

  25. Conclusion • Diagnosis of brain abscess is not difficult ! • How to early diagnosis the skull fracture and further brain damage in minor head trauma children is more important in ER!!! • Find them ,keep them, and treat them!

  26. Thank you for your attention!

More Related