急外 case conference
DESCRIPTION
急外 Case conference. Intern 黃昱豪. Patient’s Profile. Name: 劉 X 英 Age: 20 years old Gender: Female Chart Number: 22101481 Time of admission: 95-09-08 ,03:11a.m. Pre-hospital phase. Pre-hospital primary ABCDE. Event: traffic accident (motorcycle, 大順建興 ) Pre-hospital vital signs: - PowerPoint PPT PresentationTRANSCRIPT
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急外 Case conference
Intern 黃昱豪
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Patient’s Profile
Name: 劉 X 英 Age: 20 years old Gender: Female Chart Number: 22101481 Time of admission: 95-09-08 ,03:11a.m.
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Pre-hospital phase
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Pre-hospital primary ABCDE
Event: traffic accident (motorcycle, 大順建興 ) Pre-hospital vital signs: 02:59 清 , RR.:22cpm , PR:102bpm, BP:114/86mmHg ,E4V5M6 03:06 清 , RR.:22cpm , PR:100bpm, BP:120/84mmHg ,E4V5M6
Trauma evaluation: left upper extremity deformity Patient’s complaints: dyspnea, pain ,weakness AMPLE history: all denied Pre-hospital Management : Transferred by 119 with upper extremities air splints Psycological support
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Emergency department phase
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Status on arrival
Time of admission: 95-09-08 ,03:11a.m. 檢傷分級:第 2 級 AVPU:alert RR.:10-24cpm , PR:105bpm, BP:129/80mmHg< 右腳 > BT: 37’C< 耳溫 >
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PRIMARY ABCDE –Airway / Breathing
Airway : Intact On neck collar: <?> Breathing : Resp. rate: 10-24/min Breathing sound : not recorded Chest percussion: not recorded SpO2: not recorded
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PRIMARY ABCDE -Circulation
BP(RL): 129/80 mmHg Pulse: 105 beats/min Pulse assessment: not recorded Skin color assessment: pale<?>,cold<?>
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PRIMARY ABCDE -Disability
AVPU: alert GCS score: E4V5M6 Pupil: not recorded
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PRIMARY ABCDE -Exposure
left upper arm deformity Severe back pain with radiation to sternum
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PRIMARY ABCDE –problems list
1.tachycardia 2.pain 3.left upper arm deformity
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Initial Management
Pulse oximetry Medication Keto 1amp im.for pain control IV fluid N/S 1 BT ivd X-ray1.chest PA
2.L’t humeral AP+Lat.
3.L’t forearm AP+Lat Diet NPO
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X-Ray <chest AP>
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X-Ray <L’t arm>
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Initial impression
1.right side hemothorax 2.left humeral fracture 3.tachycardia, r/o hemorrhage related
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SECONDARY ABCDE- repeated general survey
1.AMPLE
2.Tubes and fingers in every orifice
3.Head to toe evaluation
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The following conditions and managements
03:44BP:126/82 mmHg, HR:111bpm
check CBC , PT/PTT, Na/K,
GOT/GPT, BUN/Cr
check CK, CK-MB, Troponin-I
follow 12-lead EKG
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Lab data 檢 體 :Blood 項 目 : WBC RBC HGB HCT MCV MCH MCHC PLT 日期 ( 時間 ) x1000/ul x10^6/ul g/dl % fl Pg g/dl x1000/ul 950908 6.69 3.01 9.2 28.3 94.0 30.6 32.5 175
檢 體 :Blood 項 目 : NA K CK Tropo-I CK-MB BUN CREA AST 日期 m mol/L m mol/L U/L ng/mL U/L mg/dl mg/dl IU/L 950908 138 3.76 1404 0.139 9.7 10.1 0.61 47
項 目 : ALT Ca++ PT p PT c PT(INR) PTT P PTT C 日期 ( 時間 ) IU/L mg% second second R second second 950908 22 4.64 12.6 10.6 1.21 30.6 29.2
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12-lead EKG
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The following conditions and managements
04:07BP:119/77 mmHg, HR:89bpm 04:40N/S 1BT ivd
arrange chest CT with and without
contrast
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Chest CT
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The following conditions and managements
05:00BP:112/75 mmHg, HR:105bpm
on chest tube 32Fr, 12cm
on CVP and add N/S 1BT
check CVP level:-3 cmH2O
on Foley
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The following conditions and managements
06:00follow chest PA 06:30follow chest PA
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The following conditions and managements
06:25add L/R 2BT ivd 06:30 BP:108/71mmHg,PR:119bpm,SpO2:96%
BT: 37.4’C, CVP level:2 cmH2O pull out CVP line to 14cm 07:40 BP:136/86mmHg,PR:127bpm,SpO2:98%
BT: 37.4’C
add N/S 1BT ivd
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The following conditions and managements
08:40follow CK, CK-MB, Troponin-I again
follow ABG
consult CVS for r/o cardiac contusion
consult CV for performing bedside
cardiac echo
consult Ortho for left arm fx
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Lab data 檢 體 :Blood 項 目 : CK Tropo-I CK-MB 日期 : U/L ng/mL U/L 950908 1404 0.139 9.7 950908 1210 0.146 11.5
檢 體 :Blood 項 目 : pH pCO2 pO2 HCO3 TCO2 BEb SBC BEecf 日期 mmHg mmHg mmol/L mmol/L mmol/L mmol/L mmol/L 950908 7.387 37.5 86.5 22.0 19.2 -2.5 22.3 -3.0
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Bedside cardiac echo
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The following conditions and managements
09:00 BP:118/76mmHg,PR:91bpm
on long arm splint 10:15 BP:111/71mmHg,PR:80bpm
BT: 38.4’C, CVP level:8 cmH2O
transfer to 15ES-ICU ward
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ER Initial diagnosis
1.right chest contusion hemorrhage 2.right hemopneumothorax 3.left humeral fracture 4.sternum fracture
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Thanks for your attention!!