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ER / Case Presentation

ER / Case Presentation. Int 陳姿吟. Patient Profile. 49 y/o male Admitted Date ： 95/10/11 15:18. Pre-hospital phase. Transferred from 輔英 H Assessment ： R/O organophosphates intoxication Head injury Management ： On endotracheal tube brain CT

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ER / Case Presentation

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  1. ER / Case Presentation Int 陳姿吟

  2. Patient Profile • 49 y/o male • Admitted Date：95/10/11 15:18

  3. Pre-hospital phase • Transferred from 輔英H • Assessment： R/O organophosphates intoxication Head injury • Management： On endotracheal tube brain CT C-spine AP, lateral、CXR、Pelvic X ray right leg X ray On NG→ green liquid N/S：2000mltoxoid Atropine

  4. Emergency Department Phase • 10/11 15:18

  5. Primary ABCDE • Airway On endotracheal tube • BreathingRR：10-24/minbreathing sound：?SpO2：? • CirculationBP：176/82 mmHg PR：75 /min

  6. Primary ABCDE • DisabilityGCS：E2VeM2-3 Light Reflex：±/±, 1/1 • Exposure/ EnvironmentBT: 35℃ Epistaxis Abrasion wound：2cm*2cm on the forehead 4cm*4cm on the right chest wall 10cm*2cm on the right knee

  7. Problem List • BP：176/82 mmHg • GCS：E2VeM2-3 Light Reflex：±/±, 1/1 • Breathing：Right upper lung lobe collapse →？foreign body underestimate on CXR • Multiple abrasion wounds, epistaxis • On NG→ green liquid

  8. Initial Management • On ventilator：TV 600ml, RR18/min, FiO2 100﹪, A/C mode • EKG, Pulse Oximeter • Lab

  9. Brain CT at 輔英H

  10. Chest PA at 輔英

  11. C-spine at 輔英

  12. Pelvic

  13. Right leg

  14. Data • Sugar 329 • CRP 0.28 • Ammonia 94 • Ethanol 2.3 • Cholinesterase 338 • Paraquat test negative • urine BZD 369.60 • WBC：3360 • RBC：5.66x106 • Hb：15.4 • Hct：48.3 • Plt：257 • BUN/CREA：13.5/1.51 • Na/K：142/3.05 • GOT/GPT：94/87 • Ca++：4.85 • PT：9.7/11.1 • INR：0.79 • aPTT：26.8/29.2 ABG： pH 7.141 PCO2 63 PO2 68.4 HCO3- 21 Base excess –9 ﹪O2sat 85.1﹪

  15. Initial Impression • Consciousness disturbance r/o organophosphates intoxication, BZD over dose • Right upper lung lobe collapse foreign body induced, r/o tooth

  16. Secondary ABCDE • 16:00 BP 178/88 PR: 73 SpO2: 87﹪ • 16:30 BP 173/87 PR: 75 SpO2: 86﹪ • AMPLE • Tubes and fingers in every orifice • Head to toe evaluation

  17. Following Conditions and Managements • 16:30 arrange brain CT with enhancement chest CT with enhancement C-spine CT with enhancement

  18. Brain CT

  19. C-spine CT

  20. Chest CT

  21. 16:50 BP158/88, PR 88, SpO2 89﹪ • 17:10 BP170/86, PR 86 E1VeM1 urine output：450ml NG 250c.c, green management：N/S 1 bot PAM 10 Amp keep 20gtt/min

  22. 18:30 BP168/88, PR 89, SpO2 88﹪ E2VeM2-3 management：N/S 1 bot • 18:40 pupil size: pin point(ou) check 12 lead EKG 轉內科 • 20:15 BP151/96, PR 96, SpO2 87﹪ 轉內科ICU

  23. 10/11 On CVC E1VeM1 • 10/12 E1VeM1 Arrange bronchoscope to remove foreign body

  24. 10/12 E1VeM1 poor urine amount liver function downhill( GOT/GPT 6945/6405, PT INR 2.18) DIC profile：FDP（-）, fibrinogen 247 D-dimer 457 thrombocytopenia

  25. 10/13 E1VeM1 Hepatoglobin 51.8 BUN/Cr 51.8/5.77 Cholinesterase 448 TCA＜0.1 PLT 9000/ul

  26. Thanks for your Attention!

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