Case presentation Case presentation

Intern 8901066 Intern 8901066 凌永耀凌永耀

Chief ComplainChief Complain

Right femoral, tibia and right forearm open Right femoral, tibia and right forearm open fracture due to traffic accident fracture due to traffic accident

The status after the traffic accidentThe status after the traffic accident

Car vs Motorcycle.Car vs Motorcycle. Coma with neck collar Coma with neck collar 固定護目位置固定護目位置 : : 右上肢，右下肢右上肢，右下肢

Respiratory Respiratory Blood Blood pressurepressure

Pulse rate Pulse rate Temperature Temperature

16/min16/min 112/90 112/90 mmHgmmHg

167/min167/min 35.4 C35.4 C

Hypovolemic shock( IV??): 1) Heart rate> 140/min2) 脈搏壓變窄3) BP down4) Respiratory rate??(>35/min)5) Urine output?? on foley

AMPLE historyAMPLE history

Unknown!!Unknown!!

ABCD ABCD 初步評估初步評估 -AB-AB

Airway / Breathing: Airway / Breathing: 需頸椎保護需頸椎保護氣道阻塞徵象氣道阻塞徵象 :Respiratory effort :Respiratory effort 氣道異物氣道異物 : : 痰痰 ++ 口水口水氣管正中氣管正中Respiratory sound: bilateral decreaseRespiratory sound: bilateral decrease

Chest X-rayChest X-ray R/O pneumothroaxR/O pneumothroax

ABCD ABCD 初步評估初步評估 -C-C

Circulation (shock?? )Circulation (shock?? )Pulse Pulse

Right side: pulseless ( fracture limb)Right side: pulseless ( fracture limb)Left side: normalLeft side: normal

Skin/ mucosa: paleSkin/ mucosa: pale骨折處持續出血骨折處持續出血 : directly decompression: directly decompression

Adequate resuscitation: Adequate resuscitation: blood pH=7.4 + U.O.= 0.5~1.0mL/kg.min blood pH=7.4 + U.O.= 0.5~1.0mL/kg.min

輸液輸液Blood loss:Blood loss:

Lower leg: 1 Units (250~ 400 c.c.)Lower leg: 1 Units (250~ 400 c.c.)Femur: 2 units ( 500~800 c.c.)Femur: 2 units ( 500~800 c.c.)

Blood loss >750 c.c.Blood loss >750 c.c.

Warm IV fluid (large-bore intravenous line)Warm IV fluid (large-bore intravenous line)Crystalloid (N/S, L/R) Crystalloid (N/S, L/R) L/R 1 BT L/R 1 BT ColloidColloid

Blood (SBP<90 or SBP<110+ PR>140)Blood (SBP<90 or SBP<110+ PR>140)

ABCD ABCD 初步評估初步評估 -D-D

Disability ( intracranial or spinal origin??)Disability ( intracranial or spinal origin??)GCS score: E1V1M2 GCS score: E1V1M2 need early intubation need early intubationPupils: sluggish right =5mm; left =3mm Pupils: sluggish right =5mm; left =3mm

Uncal herniation Uncal herniation 壓到壓到 E-W nucleus ??E-W nucleus ??

1) On O2

2) On ECG monitor

3) L/R 1 bot

4) Blood exam

5) Citosol 6 ml iv

6) Citosol 4 ml iv

7) On endo 7.5 Fr. Fix 22 cm

1600 at arrival

BP 112/90

1610

BP 102/ 85

1) On ventilator <TV 500ml, RR 16/min, FiO2 100%

2) 領 Whole blood 8U

3) 止血 : Wound treatment with air splint x 2

4) Abdominal echo <1640>

1700

BP 80/41

PR 128

1) 輸注 whole blood 4U<1700 no1, 1705 no2>

2) Citosol push 5 ml

3) On CVP<BP 121/87, PR 136, CVP 8cmH2O>

4) Consult 骨科

1730

BP 80/41

PR 128

1) 輸注 whole blood 4U<1730 no3>

2) Cefazoline 1g+ GM 80mg/ 2ml

3) N/S 1000cc

4) 借 4U PRBC

1755 BP104/80 PR 170 SpO2= 100%, CVP=3cmH2O

1) 輸血完畢，無不良反應

2) L/R 1 BOT

3) Admitted to 7ES22-19 and send to OR at 1810

PlansPlans CBCCBC GOT/GPT BUN Cr GOT/GPT BUN Cr Sugar Na KSugar Na K PT/PTTPT/PTT EthanolEthanol ABGABG Urine routineUrine routine CK CK-MBCK CK-MB Troponin-ITroponin-I

Chest: APChest: AP Pelvis: APPelvis: AP Hand: AP+ RHand: AP+ R Forearm: AP+ RForearm: AP+ R Humur: AP+ RHumur: AP+ R Foot: AP+ RFoot: AP+ R Low leg: AP+ RLow leg: AP+ R Femur: AP+ RFemur: AP+ R CT scan CT scan

For Brain (without contrast)For Brain (without contrast) For C-spine (without contrast)For C-spine (without contrast)

Available laboratory data(0604)Available laboratory data(0604)

Locate the bleedingLocate the bleeding

Echo ( FAST)Echo ( FAST)

Lung sliding: + no OPTXLung sliding: + no OPTXNegative finding for E-FASTNegative finding for E-FAST

Radiography- X rayRadiography- X ray

Chest on Chest on 0604 0604

1) No active cardiopulmonary disease.2) Status post insertion of the endotracheal tube

Pelvis AP viewPelvis AP view

Right femur AP ViewRight femur AP View

ImpressionImpression ： ： ComminuteComminuted fracture at right d fracture at right middle femoral shmiddle femoral shaft with displacemaft with displacem

ent.ent.

Right lower leg AP and Lateral ViewsRight lower leg AP and Lateral Views

ImpressionImpression ： ： FractFractures at right midures at right middle tibial and fibdle tibial and fibular shafts. ular shafts.

Right foot lateral ViewRight foot lateral View

ImpressionImpression ： ： Fracture at the Fracture at the

right 1st metatarsal right 1st metatarsal

bone. bone.

CT on brain on 0604CT on brain on 0604

LeFort I fracture

Initial diagnosis at ERInitial diagnosis at ER

1)1) Blunt head trauma (brain concussion)Blunt head trauma (brain concussion)

2)2) Blunt thoracic trauma with BCI( blunt carBlunt thoracic trauma with BCI( blunt cardiac injury) diac injury)

3)3) Multiple fractures (right forearm, right lowMultiple fractures (right forearm, right lower limb, and right foot)er limb, and right foot)

4)4) Facial bone fracture, right IMC maxillary fFacial bone fracture, right IMC maxillary fractureracture

5)5) r/o left wrist contusion with fracturer/o left wrist contusion with fracture

Chest x ray Chest x ray on 0605on 0605

1)1) Pneumomediastinum, Pneumomediastinum, soft tissue emphysema soft tissue emphysema over bilateral neck and over bilateral neck and chest wall.chest wall.

2)2) Status post insertion of Status post insertion of the endotracheal tube, the endotracheal tube, NG tube and bilateral sNG tube and bilateral subclavian central lines.ubclavian central lines.

CT on 0610CT on 0610

Low density over right cerebral Low density over right cerebral hemisphere hemisphere

Ventricular compression: +Ventricular compression: +Mid-line shift: +Mid-line shift: + Impression: acute CVD at right Impression: acute CVD at right

hemisphere favor trauma related( fatty hemisphere favor trauma related( fatty emboli may be considered emboli may be considered

Thanks a lot!!Thanks a lot!!