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Case Conference

Case Conference. 指導老師 陳昭文 醫師 Intern 張盛皇 2007.8.7. Patient’s profile. Chart NO. : 23803235 Name : 翁 XX Age : 40 y/o Sex : male Date of ER arrival : 2007.7.31 (18:30). Condition at ER. Chief complaint : falling down accidentally from second floor height this afternoon.

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Case Conference

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  1. Case Conference 指導老師 陳昭文 醫師 Intern 張盛皇 2007.8.7

  2. Patient’s profile • Chart NO. : 23803235 • Name : 翁XX • Age : 40 y/o • Sex : male • Date of ER arrival : 2007.7.31 (18:30)

  3. Condition at ER • Chief complaint : falling down accidentally from second floor height this afternoon. • Vital sign : HR= 93 bpm, BT= 36.4’C RR= 16 /min, BP=251/138 • GCS : E4V5M6 • Pupil size : L’t(3.0) R’t(2.5)

  4. Physical examination • Head : not being recorded • Neck : np • Chest : np • Abdomen : np

  5. Multiple laceration woundsover left face 3cm 12.5cm

  6. 3cm L/W with deformity of left thigh 1cm L/W of left foot

  7. L/W 2cm of right forearm L/W 1cm of left forearm

  8. Abrasion wound of left elbow Bruise of right knee

  9. Past history • DM(-) • HTN(-) • Denied any other systemic disease • Operation history:GU history post op about 10+ years ago at 台南市立 hospital

  10. Management (7/31) 18:30 -Arrival ER of KMUH Transferred from 國軍岡山 hospital Brain CT; Abd CT; symptomatic care Imp: R/O ICH with multiple L/W over face Fracture of right wrist Internal bleedinng 18:50 - CBC.GOT.GPT.BUN.Cr.Sugar.Na.K.PT.PTT - Chest x-ray. Bil wrist x-ray (AP+Lat). Left foot x-ray (AP+Lat) Left femoral x-ray (AP+Lat). Pelvic x-ray (AP). - Facial CT (non-enhanced) - L/R 1BOT IVD. Ice package. O2 4L/min. on Foley. 12-lead EKG. EKG Sp02 monitor. Air splint fixation 19:00 -Consult 骨科 & 整外 19:20 -Blood PH/gas analysis & Ethanol(quantitative) -Urine routine

  11. Management (7/31~8/1) 21:40 -L/W suture 22:20 -N/S 1BOT IVD. Gastor 1 Amp IV. Laston 1Amp IM -Debridement of the open fracture wounds -C spine collar, C spine x-ray (AP+Lat) 22:35 -PRBC 4U 23:05 -On CVP with N/S 1BOT and Chest x-ray -Gelfusine 1BOT IVD 23:15 -Consult 泌尿科 -Abd. CT -KUB 23:30 -N/S 5000ml irrigation -Right knee x-ray (AP+Lat) 00:10 -Arm splint (bil. Forearm) -Skeletal tracture (骨骼牽引) (left femorus) 01:35 -ER to 15ES SICU

  12. Management (8/2~8/6) 8/2 -Operation of left femoral neck and shaft fracture -Open reduction and internal fixation + external fixation of femoral shaft -SICU care 8/4 -Transferred to 7C 8/6 -Operation of facial bone fracture -Operation of bilateral wrist fracture→ORIF

  13. Free fall trauma Trauma 2006; 8: 157–167

  14. Epidemiology • Falls rank only 2nd to motor vehicle accidents among the causes of trauma deaths in the U.K. and U.S. • U.S. • Approximately 50% of free falls are accidental • 20% are suicide attempts • Another 20% are crime related • The remainder are from undetermined causes • Men predominate over women

  15. Risk of dying • The distance of a fall • Perhaps the strongest single predictor of mortality • Falls from 3 storeys(45 feet; 13~14m)carrying a 50% risk of death • Falls from 5 storeys(75 feet; 22~23m) or more rarely being compatible with survival • The impact surface, attitude of the body at impact, victim’s age and location of fall modify chances of survival • Immediate death from free fall is usually a result of massive brain damage, thoracic trauma or intraabdominal bleeding alone or in combination.

  16. Regional injury • Musculoskeletal injuries • The lower limbs are the most frequently encountered injuries in feet first landings. • The calcaneusis the most frequently fractured bone but complex metaphyseal and epiphyseal fracture patterns of distal joints are often seen. • Spinal injury especially to the thoraco-lumbar junction must always be suspected.

  17. The association of calcaneus fracture and spinal injury following a fall from height may be as high as 75%. • In addition, spinal injuries are commonly unstable, burst or compression type configurations and carry a high incidence of neurological injury. • Whole spine imaging is therefore warranted in any patient with calcaneus fracture following free fall.

  18. Common sequelae following falls (massive decelerations) • Ruptures of the aorta, pericardium and heart • Major hepatic and splenic injuries • However, such injuries are usually not survivable. • Always being borne in mind • In the instance of haemodynamic instability in a free fall survivor →The possibility of retroperitoneal haemorrhage especially from vertebral or pelvic fracture.

  19. Thank you for your attention!!!

  20. Back

  21. Left radial fracture; Right radial and ulnar fracture • Left 3rd toe fracture • Left femoral neck fracture; Left femoral shaft open fracture Back

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