ER / Case Presentation

Int 陳姿吟

Patient Profile 49 y/o male Admitted Date： 95/10/11 15:18

Pre-hospital phase Transferred from 輔英 H Assessment ： R/O organophosphates intoxication Head injury Management ： On endotracheal tube brain CT C-spine AP, lateral 、 CXR 、 Pelvic X ray right leg X ray On NG→ green liquid N/S ： 2000ml

toxoid Atropine

Emergency Department Phase 10/11 15:18

Primary ABCDE Airway

On endotracheal tube Breathing

RR ： 10-24/minbreathing sound ： ?SpO2 ： ?

CirculationBP ： 176/82 mmHg

PR ： 75 /min

Primary ABCDE

DisabilityGCS ： E2VeM2-3

Light Reflex ： ±/±, 1/1

Exposure/ EnvironmentBT: 35℃

Epistaxis Abrasion wound ： 2cm*2cm on the forehead 4cm*4cm on the right chest wall 10cm*2cm on the right knee

Problem List

BP ： 176/82 mmHg GCS ： E2VeM2-3

Light Reflex ： ±/±, 1/1 Breathing ： Right upper lung lobe collapse

→ ？ foreign body underestimate on CXR

Multiple abrasion wounds, epistaxis On NG→ green liquid

Initial Management On ventilator ： TV 600ml, RR18/min, FiO2 100 ,﹪ A/C mode EKG, Pulse Oximeter Lab

Brain CT at 輔英 H

Chest PA at 輔英

C-spine at 輔英

Pelvic

Right leg

Data WBC ： 3360 RBC ： 5.66x106 Hb ： 15.4 Hct ： 48.3 Plt ： 257 BUN/CREA ： 13.5/1.51 Na/K ： 142/3.05 GOT/GPT ： 94/87 Ca++ ： 4.85 PT ： 9.7/11.1 INR ： 0.79 aPTT ： 26.8/29.2

• Sugar 329

• CRP 0.28

• Ammonia 94

• Ethanol 2.3

• Cholinesterase 338

• Paraquat test negative

• urine BZD 369.60

ABG：

pH 7.141

PCO2 63

PO2 68.4

HCO3- 21

Base excess –9

﹪O2sat 85.1﹪

Initial Impression

Consciousness disturbance

r/o organophosphates intoxication, BZD over dose Right upper lung lobe collapse

foreign body induced, r/o tooth

Secondary ABCDE

16:00 BP 178/88 PR: 73 SpO2: 87﹪ 16:30 BP 173/87 PR: 75 SpO2: 86﹪

AMPLE Tubes and fingers in every orifice Head to toe evaluation

Following Conditions and Managements 16:30 arrange brain CT with enhancement

chest CT with enhancement

C-spine CT with enhancement

Brain CT

C-spine CT

Chest CT

16:50 BP158/88, PR 88, SpO2 89﹪ 17:10 BP170/86, PR 86

E1VeM1

urine output ： 450ml

NG 250c.c, green

management ： N/S 1 bot

PAM 10 Amp keep 20gtt/min

18:30 BP168/88, PR 89, SpO2 88﹪ E2VeM2-3

management ： N/S 1 bot 18:40 pupil size: pin point(ou)

check 12 lead EKG

轉內科 20:15 BP151/96, PR 96, SpO2 87﹪ 轉內科 ICU

10/11 On CVC E1VeM1 10/12 E1VeM1

Arrange bronchoscope

to remove foreign body

10/12 E1VeM1

poor urine amount

liver function downhill( GOT/GPT 6945/6405,

PT INR 2.18)

DIC profile ： FDP （ - ） , fibrinogen 247

D-dimer 457

thrombocytopenia

10/13 E1VeM1

Hepatoglobin 51.8

BUN/Cr 51.8/5.77

Cholinesterase 448

TCA ＜ 0.1

PLT 9000/ul

Thanks for your Attention!