Case ConferenceCase Conference

Int.Int. 林美琪林美琪96/04/0396/04/03

Patient profilePatient profile

►李李季季 , 27y/o, male, 27y/o, male►Chart num.:16897970Chart num.:16897970►Admission to ER date: 96/03/30 04:36Admission to ER date: 96/03/30 04:36►Way of admission: 119Way of admission: 119►Discharge from ER date: 96/03/31 12:30Discharge from ER date: 96/03/31 12:30

Injury mechanismInjury mechanism

►According to the inhabitant’s descriptioAccording to the inhabitant’s description, a great sound “bump” was heard. Falln, a great sound “bump” was heard. Falling down was suspected, but there is no wing down was suspected, but there is no witness.itness.

►現場生命徵象現場生命徵象 : Coma(E1V1M1): Coma(E1V1M1)

Pre-hospital evaluation and Pre-hospital evaluation and managementmanagement

► sent to KMUH ERsent to KMUH ER► Head: ILOC(+), dizziness(?), headache(?), nausea/vomitiHead: ILOC(+), dizziness(?), headache(?), nausea/vomiti

ng(?), amnesia(?), vertigo(?)ng(?), amnesia(?), vertigo(?)► Neck: pain(?), stiff(?), soreness(?)Neck: pain(?), stiff(?), soreness(?)► Chest: pain(?), dyspnea(?)Chest: pain(?), dyspnea(?)► Abdomen: pain(?), discomfort(?) Abdomen: pain(?), discomfort(?) ► Limbs and skin : Limbs and skin : Bilateral forearm deformity, Bilateral forearm deformity, Right knee abrasion wound,Right knee abrasion wound, Face deep laceration wound, Face deep laceration wound, Mandible deformityMandible deformity 頸圈頸圈 , , 長背板固定長背板固定 , , 左右手木板固定左右手木板固定 , , 傷口包紮傷口包紮 , , 評估意識及生命跡象評估意識及生命跡象

Initial evaluation (KMUH)Initial evaluation (KMUH)

A (airway) / B (breathing):A (airway) / B (breathing): RR:20cpm, SpORR:20cpm, SpO22:70%:70% Collar fixation: needCollar fixation: need Airway: respiration: not smoothAirway: respiration: not smooth airway obstruction sign:airway obstruction sign:

cyanotic and stridercyanotic and strider blood in the mouthblood in the mouth trachea: mid-positiontrachea: mid-position breathing sound: bilateral ralesbreathing sound: bilateral rales

C (circulation):C (circulation): Rate: 64 bpmRate: 64 bpm

brachial a.: normalbrachial a.: normal carotid a. : normalcarotid a. : normal femoral a.: normalfemoral a.: normal dorsalis pedis a.: normaldorsalis pedis a.: normal

Cuff BP: 123/104 mmHgCuff BP: 123/104 mmHg Skin condition: appearance: not paleSkin condition: appearance: not pale temp: warm (36.2’C)temp: warm (36.2’C) humidity: normalhumidity: normal Suspect: facial bone fracture and subcutaneous hematoSuspect: facial bone fracture and subcutaneous hemato

mama

D (disable):D (disable): GCS: E1V1M1GCS: E1V1M1 Pupil :Pupil :

od: 1mm, (-/-)od: 1mm, (-/-)os: 4mm, (-/-)os: 4mm, (-/-)

E (exposure):E (exposure): L’t face deep laceration (7cm) L’t face deep laceration (7cm) L’t and R’t forearm deformity L’t and R’t forearm deformity R’t knee abrasions woundR’t knee abrasions wound No bruise over bilateral buttock and hip arNo bruise over bilateral buttock and hip ar

eaea No urethra meatus bloody dischargeNo urethra meatus bloody discharge

Initial ResuscitationInitial Resuscitation

► On endotracheal tube (#7.5, fix 22cm) and assist On endotracheal tube (#7.5, fix 22cm) and assist ventilation ventilation RR:24/min, TV:700ml, FiORR:24/min, TV:700ml, FiO22:40%:40%

► Maintain cardiac monitor Maintain cardiac monitor ► Insert 2 large-born IV line and rapid infusion of cInsert 2 large-born IV line and rapid infusion of c

rystalloid solution (N/S and L/R)rystalloid solution (N/S and L/R)► On CVCOn CVC► On foley and OGOn foley and OG► Collect blood sample and urine routine for initial Collect blood sample and urine routine for initial

laboratory studies laboratory studies

Initial Radiographic StudiesInitial Radiographic Studies

►Brain CT Brain CT (without contrast)(without contrast) subarachnoid hemorrhage in left Sylvian fissursubarachnoid hemorrhage in left Sylvian fissur

e, left fronto-parietal regions and basal cisterne, left fronto-parietal regions and basal cistern brain edemabrain edema skull base fractureskull base fracture bilateral maxillary and mandible fracturebilateral maxillary and mandible fracture hemosinus in all paranasal sinuseshemosinus in all paranasal sinuses

►FAST : no intra-abdominal free fluid accumFAST : no intra-abdominal free fluid accumulationulation

►Left forearm Left forearm AP and Lat X-rayAP and Lat X-ray left distal radial and ulnar fracture, closed left distal radial and ulnar fracture, closed

►Right forearm Right forearm AP and Lat X-rayAP and Lat X-ray►Right knee Right knee AP and Lat X-rayAP and Lat X-ray►Right elbow Right elbow AP and Lat X-rayAP and Lat X-ray

right humeral fracture, closedright humeral fracture, closed►Chest X-rayChest X-ray

► 12-Lead EKG12-Lead EKG► C-spine CTC-spine CT

Subarachnoid hemorrhage in the basal cistern and exSubarachnoid hemorrhage in the basal cistern and extending into cervical thecal sac.tending into cervical thecal sac.

Fractures of left posterior tubercle & left inferior articFractures of left posterior tubercle & left inferior articular facet of C6, left posterior tubercle of C7, left transular facet of C6, left posterior tubercle of C7, left transverse process of T1, T2, and left 1st, 2nd ribs.verse process of T1, T2, and left 1st, 2nd ribs.

► Pelvis CTPelvis CT No image evidence of pelvic fractureNo image evidence of pelvic fracture

Past historyPast history► IV drug abuser (heroin addiction)IV drug abuser (heroin addiction)►DM (-) DM (-) ►HTN (-)HTN (-)►Hepatitis B or C carrier: deniedHepatitis B or C carrier: denied►Op. hx.: deniedOp. hx.: denied►Allergy hx.: deniedAllergy hx.: denied►Family hx.: non-contributory Family hx.: non-contributory

Lab dataLab data

Tentative diagnosisTentative diagnosis

►head injury /c skull base fracture /c traumhead injury /c skull base fracture /c traumatic SAHatic SAH

►bilateral maxillary and mandible fracturebilateral maxillary and mandible fracture►right humeral fracture, closedright humeral fracture, closed► left distal radial and ulnar fracture, closedleft distal radial and ulnar fracture, closed

Ongoing Evaluation & Ongoing Evaluation & Resuscitation Resuscitation

► Monitor vital sign and conscious level Monitor vital sign and conscious level ► Evaluate the evidence of new or ongoing signs oEvaluate the evidence of new or ongoing signs o

f shock f shock ► Antibiotics usage: cefazolin + GM Antibiotics usage: cefazolin + GM ► Keep patients warm Keep patients warm ► Consult NS: admitted to NS ICU for further careConsult NS: admitted to NS ICU for further care► Consult OW: casting the elbow and forearm fractConsult OW: casting the elbow and forearm fract

ureure

After admissionAfter admission

►03/31 PM4:35: BP drop and pulseless03/31 PM4:35: BP drop and pulseless Bosmin 1 Amp iv.Bosmin 1 Amp iv. Dopamin 4 Amp + N/S 500ml Keep 30 ml/hr Dopamin 4 Amp + N/S 500ml Keep 30 ml/hr Sigh DNR, then AADSigh DNR, then AAD

Thanks for your Thanks for your attention!!attention!!

mandible fracturemandible fracturemaxillarymaxillary fractureracturehemosinushemosinus

sphenoid bonesphenoid bone (skull base) fract (skull base) fractureure

Subarachnoid hemorrhage

Brain edema