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Trauma Case Conference

2007-7-17 外傷科 Intern 趙家宏. Trauma Case Conference. Patient Profile. 馬王○雪， 28y/o ， Female Date of ER visiting ： 2007-07-09 Mechanism of Injury ：計程車副駕駛乘客，卡在椅子和手套之間 Sent to our ER at 05:44 AM by EMT. Condition at Scene. Vital sign: BP 105/59, T/P/R:36.9/111/10 AVPU ： Unrespondsive,

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Trauma Case Conference

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  1. 2007-7-17 外傷科 Intern 趙家宏 Trauma Case Conference

  2. Patient Profile 馬王○雪，28y/o，Female Date of ER visiting：2007-07-09 Mechanism of Injury：計程車副駕駛乘客，卡在椅子和手套之間 Sent to our ER at 05:44 AM by EMT

  3. Condition at Scene Vital sign: BP 105/59, T/P/R:36.9/111/10 AVPU：Unrespondsive, GCS scale: Ｅ1V1M5, Consciousness: coma On neck collar

  4. Resuscitation • Start resuscitation on 5:44 AM • On E-T tube Fr-7.5, fixed 22 cm • IVF: L/R 1000 cc, N/S:1000cc • On Monitor • On neck collar

  5. Primary Survey and Management Airway On oral endotracheal tube Assume a cervical spine injury and on neck collar Breathing Artificial ventilation Decompression and drainage of tension pneumothorax/haemothorax

  6. Primary Survey and Management Circulation with haemorrhage control Stop external haemorrhage Establish 2 large-bore IV lines (14 or 16 G) if possible with administer fluids Disability A V P U: unresponsive Exposure Left knee laceration wound 5-6 cm

  7. Primary Survey and Management Lab CBC, DC, CRP GOT,GTP, Bun, Cr, Na, K PT,PTT Troponin-I, CPK, CK-MB X-ray CXR Pelvic CT Brain Wound CD and suture laceration wound with nylon 4-0

  8. 2007/7/9 6:00 AM

  9. 2007/07/09 6:00 Brain CT

  10. Brain CT finding • Traumatic subarachnoid hemorrhage with rupture into ventricles. • Suspect subdural hemorrhage along the anterior falx. • Right pneumothorax with left hemothorax • On endotracheal tube. • No imaging evidence of C-spine fracture.

  11. Lab

  12. Secondary Survey and Management Airway On oral endotracheal tube On neck collar Breathing R’t pneumothorax and left hemothorax Artificial ventilation On chest tube (6:25 AM)

  13. Secondary Survey and Management Circulation with haemorrhage control PRBC 2u at 9:00AM Disability and Differential Diagnosis SAH and SDH consult NS Elevated liver enzyme: liver laceration is suspected Arrange abdominal CT Exposure Left knee laceration wound with suture line

  14. Chest X-ray 7:30chest tube 太深，外拉2cm

  15. Abdomen CT <8:00 AM>

  16. Abdominal CT finding • Liver laceration injury of S8 of r’t hepatic lobe , with hemoperitoneum, AAST:Gr III-IV, cannot rule out active bleeding • Hemopericardium • Bil hemothorax

  17. Impression • Traumatic SAH and IVH • R’t pneumothorax • left hemothorax • Liver laceration Gr III-IV • Hemopericardium r/o cardiac temponade

  18. Resuscitation • 10:00 AM • Give hyperventilation, FiO2 set 30% • 輸血PRBC 2U(9:00), 備血PRBC6U • 10:20AM • BP86/45 PR120/min • Keep blood transfusion • PE: BS, bil present, coarse over l’t side, mild decrease over r’t side, Abdomen: soft • Consult HBS surgeon • Consult CVS

  19. HBS surgery 7/9 Dx:Liver laceration Laparotomy+hepatorrhaphy+choleycystostomy+ packing of liver 7/13 Liver packing gauze remove

  20. CVS surgery • 7/9r/o hemopericardium , Ant mediestinum hematoma • Explore pericardiotomy <No hemopericardium, ,inimal pericardial effusion> • Fr 28 chest inserted to the substernal space • 7/10 r/oAnt mediestinum hematoma, manubrium fracture • Sternum ORIF, check bleeding

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