Emergency department Case report

Date: 2006.09.14Intern 韓易庭

Patient profile

Name: 陳雷 XAge: 19y/oGender: maleChart number: 23119114Room number: 18ES 55Admitted time: 95.09.16 PM 20:39

Pre-hospital phase Transferred from 小港 hospital Event: Hit by iron rod in chest and abdomen while wor

king Pre-hospital vital signs: unknown AMPLE: unknown Trauma evaluation:

Chest and abd blunt injurySpleen lacerationLeft kidney lacerationLeft pneumothoraxLeft Colles’ fracture

Emergency Treatment: L/R 1500ml, N/S 100ml, Aspegic, Transamin, Demerol Chest CT, Abd CT

Status on arrival PM 20:39

Conscious: alertRespiration: 10~24 cpmBlood pressure: 119/41 mmHgPulse rate: 99 bpmBody temperature: 36 degree檢傷分級： 1st degreeFoley:????????

Chief complaint and observation(patient and family)Dyspnea? chest tightness? Left wrist pain?Left abdominal distension? Tnederness?

Discomfort?

Primary ABCDE

Open pneumothorax Tension pneumothorax

Cardiac temponade

Airway obstruction

Flail chestMassive hemothorax

Exposure Disability Circulation BreathingAirway

Immobilization percussion Skin color Pupil size Echymosis

Obstruction RR, BS BP, PR GCS Deformity

Primary ABCDE

AirwayBreathingCirculationDisabilityExposure

Conscious: alertRespiration: 10~24 cpm

Blood pressure: 119/41 mmHgPulse rate: 99 bpm

Body temperature: 36 degree

Initial Management PM 20 ： 53

N/S 1000ml IVDEKG, SpO2 monitor Nasal cannula 4L/minCXR, KUB, Left forearmCBC, PT/PTT, Blood type cross testConsult UroConsult GS On CVP, left subclavian Abdominal CT

SpO2 99%

Image from 小港

Image from 小港

Image from 小港

Image

Image: intravenous urography (IVU)

Image

Abdominal CT

Lab data 950916 PM 20:53

一般血液檢驗 檢 體 :Blood 項 目 : WBC RBC HGB HCT MCV MCH MCHC 日期 ( 時間 ) x1000/ul x10^6/ul g/dl % fl Pg g/dl 950909 29.65 2.59 7.60 23.6 91.1 29.3 32.2

檢 體 :Blood 項 目 : PLT RDW-CV RDW-SD 日期 ( 時間 ) x1000/ul % fl 950909 139 13.2 44.3

Lab data 950916 PM 20:53

PT P:13.1 secondPT C:10.7 secondPT(INR): 1.30 RPTT P: 26.8 secondPTT C: 29.5 second

Lab data 950916 PM20:53

Glu(AC): 153 mg/dlGOT: 46IU/LGPT: 34IU/LBUN(B): 15 mg/dlCRTN(B): 1.43 mg/dlCK: 256 IU/LCK-MB: 53 IU/LAmylase: 49 IU/L

Problem list

Internal bleeding: spleen and L’t kidney laceration

PneumothoraxLeft Colles’ fracture

Spleen injury scale (1994 revision)Grade I Subcapsular hematoma of less than 10% of surface area Capsular tear of less than 1 cm in depthGrade II Subcapsular hematoma of 10-50% of surface area Intraparenchymal hematoma of less than 5 cm in diameter Laceration of 1-3 cm in depth and not involving trabecular vesselsGrade III Subcapsular hematoma of greater than 50% of surface area or expanding and ruptured subcapsular or parenchymal hematoma Intraparenchymal hematoma of greater than 5 cm or expanding Laceration of greater than 3 cm in depth or involving trabecular vesselsGrade IV Laceration involving segmental or hilar vessels with devascularization of more than 25% of the spleen Grade V Shattered spleen or hilar vascular injury

Kindey injury scale (Moore 1989)Grade 1 Hematuria with normal imaging studies Contusions Nonexpanding subcapsular hematomasGrade 2 Nonexpanding perinephric hematomas confined to the retroperitoneum Superficial cortical lacerations less than 1 cm in depth without collecting system injuryGrade 3 Renal lacerations greater than 1 cm in depth that do not involve the collecting system Grade 4 Renal lacerations extending through the kidney into the collecting system Injuries involving the main renal artery or vein with contained hemorrhage Segmental infarctions without associated lacerations Expanding subcapsular hematomas compressing the kidneyGrade 5 Shattered or devascularized kidney Ureteropelvic avulsions Complete laceration or thrombus of the main renal artery or vein

The spleen, 75-150 g, is a highly vascular organ that filters an estimated 10-15% of total blood volume every minute.

One kidney 150 cc, One Renal blood flow 600ccCounts for ¼ of cardica output , about 1200cc/min.

Secondary ABCDE Secondary ABCDE

From Head to Toe

• Laceration wound• Tracheal deviation• Jugular venous

engorgement • Subcutaneous

emphysema

• Speculation• Palpation• Percussion• Auscultation• Fracture• Laceration wound

• Speculation• Palpation • Percussion• Auscultation• Fracture

• Distal palpation• Sensation• Range of motion• Split• Laceration wound

• Tenderness point• Deformities• Fracture

Chest Pelvic Extremities Back and hipHead and Neck

Time line

PM 21:10 PRBC 2UGelofusine 4% 1BTN/S 500ml IVD烤燈

PM 21:30

PM 22:00On chest tube 32#

left, keep 10cmF/U CXR

BP ： 73/30 mmHg PR: 94bpm

SpO2: 100% CVP level: 2cm H2O

BP ： 121/61 mmHg PR: 88bpm

SpO2: 100%

BP ： 114/71 mmHg PR: 104bpm SpO2: 100%

Image

Time line

PM 22:30 PRBC 2U OPFFP 6UPre-Op order

Sign op permitSign op schedule NPON/S 500mlMorphine 5ml IV st

BP ： 137/72 mmHg PR: 102bpm SpO2: 100%

BT: 36.3 degreeE4V5M6

Assessment

Internal bleeding, Spleen rupture (Gr II)L’t kidney rupture (Gr II)

L’t pneumothorax with lung contussionR’t pneumothoraxL’t radius fracture Colle’s fracture

References

Emergency Trauma Training CourseACLS 精華 3rd editionSabiston Textbook of Surgery 17 th deitio

neMedicine 10/21/2002Moore 1989

Thank you for your attention !!!!!!!