Case 1

1. Case 1 CR2 莊景勛 2007/08/28

2. Patient’s Profile • Name: 林X琪 • Gender: female • Age: 14 years old • Chart number: 23731066 • Arrival time: 2007/07/1, 16:42

3. Arrival status • GCS: E1V1M4 • Vital signs: ?, 71, 12, 140/91 • neck collar (+) • Splint (+)

4. Primary survey • Airway/Breathing - on neck collar - intubation with mechanical ventilation - on SpO2 monitor

5. Primary survey • Circulation - on EKG monitor, HR 71, BP 140/91 - set IVF with N/S - no external hemorrhage • Disability - E1VeM4 - pupil: 5.0mm L/R - (R), 2.0mm L/R - (L)

6. Present Illness • traffic accident (motorcycle) at 16 PM of 7/1 • conscious disturbance • left bloody otorrhea • left thigh swelling • multiple abrasion over four limbs

7. Past History • systemic disease: ? • allergies: ? • OP history: ?

8. Management at ER • check laboratory data • X-ray (chest, left femur) • brain CT + C-spine CT • on foley • on OG • on CVP

11. Brain CT 1) Subdural hematoma in right fronto-temporo-parietal regions 2) Brain edema with right subfalcine and uncal herniation 3) Subgaleal hematoma of left frontoparietal regions 4) Suspect longitudinal fracture of left temporal lobe with pneumocephalus and subcutaneous emphysema at left parapharyngeal space

12. C-spine CT 1) no abnormality of cervical spine 2) pulmonary contusion at bilateral apices and pneumothorax of left lung

13. Initial Diagnosis • right SDH, skull base fracture, subgaleal hematoma • left femoral shaft fracture • multiple abrasion over four limbs

14. Management at ER • consult NS, ortho. • arrange emergent operation • admit to ICU (NS)

15. Case 2

16. Patient’s Profile • Name: 唐X晴 • Gender: female • Age: 6 years old • Chart number: 23769713 • Arrival time: 2007/07/17, 7:32

17. Arrival status • GCS: E2V1M1(?) • Vital signs: ?, 132, 14, 111/69 • neck collar (+) • Splint (+)

18. Primary survey • Airway/Breathing - on neck collar - no airway obstruction sign - nasal O2 2L/min - on SpO2 monitor, RR 14, SpO2 100%

19. Primary survey • Circulation - on EKG monitor, HR 141, BP 94/52 - set IVF with N/S - no external hemorrhage • Disability - E3V3M4 - pupil: ?

20. Present Illness • fell from height (5F?) at 7 AM of 7/17 • abdominal pain • multiple abrasion over extremities

21. Past History • systemic disease or congenital disease: ? • allergies: ? • OP history: ?

22. Management at ER • check laboratory data • ice packing • X-ray (chest, C-spine, pelvis including femur) • abdominal CT (C- and C+) • on foley  hematuria

26. Abdominal CT 1) Bilateral pneumothorax 2) Suspect hematoma in left hepatic lobe adjacent to gallbladder fossa 3) Fracture of right femoral intertrochanteric region, left pubic bone and right 11th rib 4) Contusion hemorrhage in right lung

27. Initial Diagnosis • bilateral pneumothorax • blunt abdominal trauma, liver laceration, pancreatic contusion • pelvic fracture • right femoral neck fracture • right distal femoral shaft fracture • R/O renal contusion, R/O urethral injury

28. Management at ER • consult pediatric surgeon, orthopedist • on bilateral chest tube • admit to ICU (pediatric surgery)

29. Case 3

30. Patient’s Profile • Name: 陳X菁 • Gender: female • Age: 3 years old • Chart number: 23773129 • Arrival time: 2007/07/18, 12:41

31. Arrival status • GCS: E3V5M6 • Vital signs: 38.2, 80, 14, 79/53 • neck collar (-) • Splint (+)

32. Primary survey • Airway/Breathing - no neck collar - no airway obstruction sign - smooth breathing pattern with room air - on SpO2 monitor, RR 14, SpO2 100% - clear breathing sound and symmetric

33. Primary survey • Circulation - on EKG monitor, HR 80, BP 79/53 - set IVF with N/S - no external hemorrhage • Disability - E3V5M6 - pupil: 3.0 mm, L/R + (L), not check, due to periorbital swelling (R)

34. Present Illness • traffic accident (motorcycle vs truck) at 9 AM of 7/18 • helmet (-) • referred from local hospital (impression: right femoral fracture, r/o facial bone fracture) • swelling and ecchymosis over right periorbital area

35. Present Illness • abdominal pain • right thigh swelling

36. Past History • denied systemic disease and congenital disease • allergies: nil • OP history: nil

37. Management at ER • check laboratory data • ice packing • chest X-ray • 外片入PACS • FAST  fluid accumulation over left spleno-renal fossa • arrange abdominal CT (C- and C+) • arrange brain CT + facial bone CT

38. 1) Right clavicle fracture 2) Suspect fractures at the posterior aspect of right 9th to 11th ribs

39. Abdominal CT 1) lacerations of the liver, mainly in right hepatic lobe 2) suspect hematoma in the left perirenal space 3) fractures of the right 9th, 10th and 11th ribs 4) minimal right pneumothorax 5) mild right pleural effusion and ascites

40. Brain CT + Facial bone CT 1) right frontal, temporal, and parietal bone fractures with scalp swelling and pneumocephalus 2) mild right frontoparietal subdural hemorrhage

41. Initial Diagnosis • blunt head trauma, skull fracture, right frontoparietal subdural hemorrhage • liver laceration with hemoperitoneum • left renal contusion • pelvic fracture • right femoral shaft fracture • right clavicle fracture • right ribs fracture with pneumothorax

42. Management at ER • consult NS, ortho. • on foley, check urine routine • admit to ICU (NS)

43. Thanks for Your Attention!!!