Case Presentation

Presenter : 8901157 Intern 黃曉禹

Brief History referred from 小港 Male 54y/o 07431690 Conscious : clear??,

E4V5M5 1200 TA

close pelvic fracture 左前胸 , 左臉 , 左手 ,

左腳 開放性傷口紗布

小港 6600 cc fluid 1 2-way CVP line

1. PRBC 1U 2. Gelofusin 1 BT

2 peripheral line right hand IV with N/

S right foot iv with N/S

1st assessment (950817 1438) Airway:

patent no need neck protect Can talk

Breathing:10-24 obstruction: nil foreign:nil tracheal deviation: ni

l

Circulation :74/40 skin: pale temperature warm moist : normal Pulse:normal Bleeding : ??

Disability : E3V5M6 GCS=14

Expose / Enviroment

2nd assessment Allergy : nil Medication : 胃藥 Past illness: 胃痛 Last meal : 950817 1200 Events : Traffic accident, crushing injury

小港 H suggest angiography & embolization

General survey : Left ant face , chest, left upper limbs & lower limb

s open wound, no active bleeding

Initial management 1440

O2 4L/min blood exam n/s 1000ml ivd on EKG monitor On oxymeter 備血

PRBC 6U FFP 6U PLT 12U

1457 arrange angiography, sign permit

1440 SaO2 94%

1500 BP 95/50 p90 N/S 1 BT

1515 BP 84/38, p88 Send angio room

Pelvic fracture Force?

前後 -pelvic unstable + threatening hypotension

側面 - bladder & ureter injury

垂直 - pelvic unstable Volume status

6600cc in about < 3hr Hypovolemic status Fluid resuscitation

3:1 crystaloid : blood loss

Crushing injury>3:1(more crystaloid)

Progressive bleeding <3:1 (more blood)

小港 lab data WBC 6280/ul RBC 5.2 HGB 15.4 HCT 45.9 PLT 184 PT P/PT C= 11.9 /

10.7 PTT P/ PTT C =

28.7 / 1.65

GOT/GPT 31/29 BUN/CREA

22.8/1.65 NA/K=137/3.8 GLU 245

1440 blood exam Distal upper

limb 150-250 Proximal

upper limb 250

Distal lower limb 500

Proximal lower limb 1000

Pelvic 1500-3000

小港 CT

Angiography & embolization

angiography

The aortogram, bilateral internal iliac arteriography reveal extravasation via the left superior gluteal artery.

2nd management --back from angio room -- continue bleeding 1720 consult OW

whole blood 10 U 1740

BP 112/78 P102 PRBC 2U 無不適 DOPAMINE 2 amp + N/S 1 BT keep 10 gtt/min

1810 P RBC *2 BP121/76 P102 FFP 2U * 2 P RBC * 2

1850 N/S 1BT + transamine 1 amp

1905 BP 109/72 P103 Sao2 100%

2nd management --back from angio room -- continue bleeding 1910

sign permit NPO N/S 1 Bt + trasamine 2amp IVD

chest-x-ray PA view 1930 BP: 107/59 PR 101 2010 BP: 99/59 P102

2035 BP 98/53 P120 SaO2:100%

2040 blood exam ABD CT enhanced

2050 sent p't to CT room 95/50 P128 Sao2 100%

Source of bleeding ?? Open wound

左前胸 左臉 左手 左腳

Image 2

Chest x-ray Abdomen CT CBC

3th management -- prepare to OR 2110

BP 120/55 P130 SaO2 100% PLT 輸畢無不適

2112 sinus tachycardia

2115 whole blood consult GS

2130: 97/62 P68 Sao2 100% non-rebreathing mask

use 10 L/min

3th management -- prepare to OR 2135

s: dyspnea Sao2 100% On endo

citosol + aq dest1amp-->5u iv

on endo fix 23cm PRN surgeon on ventilator TV 600ml ra

te 8 times/min 2142

EKG sinus tachycardia 2200

BP:104/69 PR118 whole Blood

2215 BP101/69 PR138 sent to OR & 15ESI 1-8

On endo

OR

splenectomy

Impression

Pelvic fracture Hypovolemic shock Spleen laceration Left Kidney parechyma injury Mixed type acidosis, metabolic acidos

is + respiratory acidosis

Thanks for your attention