Case 1

CR2 莊景勛2007/08/28

Patient’s Profile• Name: 林 X琪• Gender: female• Age: 14 years old• Chart number: 23731066• Arrival time: 2007/07/1, 16:42

Arrival status

• GCS: E1V1M4• Vital signs: ?, 71, 12, 140/91• neck collar (+)• Splint (+)

Primary survey

• Airway/Breathing

- on neck collar

- intubation with mechanical ventilation

- on SpO2 monitor

Primary survey

• Circulation

- on EKG monitor, HR 71, BP 140/91

- set IVF with N/S

- no external hemorrhage • Disability

- E1VeM4

- pupil: 5.0mm L/R - (R), 2.0mm L/R - (L)

Present Illness• traffic accident (motorcycle) at 16 PM of

7/1• conscious disturbance• left bloody otorrhea• left thigh swelling• multiple abrasion over four limbs

Past History

• systemic disease: ?• allergies: ?• OP history: ?

Management at ER• check laboratory data • X-ray (chest, left femur)• brain CT + C-spine CT • on foley• on OG• on CVP

Brain CT

1) Subdural hematoma in right fronto-temporo-parietal regions

2) Brain edema with right subfalcine and uncal herniation

3) Subgaleal hematoma of left frontoparietal regions

4) Suspect longitudinal fracture of left temporal lobe with pneumocephalus and subcutaneous emphysema at left parapharyngeal space

C-spine CT

1) no abnormality of cervical spine

2) pulmonary contusion at bilateral apices and pneumothorax of left lung

Initial Diagnosis

• right SDH, skull base fracture, subgaleal hematoma

• left femoral shaft fracture• multiple abrasion over four limbs

Management at ER

• consult NS, ortho.• arrange emergent operation• admit to ICU (NS)

Case 2

Patient’s Profile• Name: 唐 X晴• Gender: female• Age: 6 years old• Chart number: 23769713• Arrival time: 2007/07/17, 7:32

Arrival status

• GCS: E2V1M1(?)• Vital signs: ?, 132, 14, 111/69• neck collar (+)• Splint (+)

Primary survey

• Airway/Breathing

- on neck collar

- no airway obstruction sign

- nasal O2 2L/min

- on SpO2 monitor, RR 14, SpO2 100%

Primary survey

• Circulation

- on EKG monitor, HR 141, BP 94/52

- set IVF with N/S

- no external hemorrhage • Disability

- E3V3M4

- pupil: ?

Present Illness• fell from height (5F?) at 7 AM of 7/17• abdominal pain• multiple abrasion over extremities

Past History

• systemic disease or congenital disease: ?

• allergies: ?• OP history: ?

Management at ER• check laboratory data • ice packing• X-ray (chest, C-spine, pelvis including f

emur)• abdominal CT (C- and C+)• on foley hematuria

Abdominal CT

1) Bilateral pneumothorax

2) Suspect hematoma in left hepatic lobe adjacent to gallbladder fossa

3) Fracture of right femoral intertrochanteric region, left pubic bone and right 11th rib

4) Contusion hemorrhage in right lung

Initial Diagnosis

• bilateral pneumothorax• blunt abdominal trauma, liver laceration,

pancreatic contusion• pelvic fracture• right femoral neck fracture• right distal femoral shaft fracture• R/O renal contusion, R/O urethral injury

Management at ER

• consult pediatric surgeon, orthopedist• on bilateral chest tube• admit to ICU (pediatric surgery)

Case 3

Patient’s Profile• Name: 陳 X菁• Gender: female• Age: 3 years old• Chart number: 23773129• Arrival time: 2007/07/18, 12:41

Arrival status

• GCS: E3V5M6• Vital signs: 38.2, 80, 14, 79/53• neck collar (-)• Splint (+)

Primary survey

• Airway/Breathing

- no neck collar

- no airway obstruction sign

- smooth breathing pattern with room air

- on SpO2 monitor, RR 14, SpO2 100%

- clear breathing sound and symmetric

Primary survey

• Circulation

- on EKG monitor, HR 80, BP 79/53

- set IVF with N/S

- no external hemorrhage • Disability

- E3V5M6

- pupil: 3.0 mm, L/R + (L), not check, due to

periorbital swelling (R)

Present Illness• traffic accident (motorcycle vs truck) at 9

AM of 7/18• helmet (-)• referred from local hospital (impression:

right femoral fracture, r/o facial bone fracture)

• swelling and ecchymosis over right periorbital area

Present Illness

• abdominal pain • right thigh swelling

Past History

• denied systemic disease and congenital disease

• allergies: nil• OP history: nil

Management at ER• check laboratory data • ice packing• chest X-ray• 外片入 PACS• FAST fluid accumulation over left spl

eno-renal fossa• arrange abdominal CT (C- and C+)• arrange brain CT + facial bone CT

1) Right clavicle fracture

2) Suspect fractures at the posterior aspect of right 9th to 11th ribs

Abdominal CT

1) lacerations of the liver, mainly in right hepatic lobe

2) suspect hematoma in the left perirenal space

3) fractures of the right 9th, 10th and 11th ribs

4) minimal right pneumothorax5) mild right pleural effusion and ascites

Brain CT + Facial bone CT

1) right frontal, temporal, and parietal bone fractures with scalp swelling and pneumocephalus

2) mild right frontoparietal subdural

hemorrhage

Initial Diagnosis• blunt head trauma, skull fracture, right frontop

arietal subdural hemorrhage• liver laceration with hemoperitoneum• left renal contusion• pelvic fracture• right femoral shaft fracture• right clavicle fracture• right ribs fracture with pneumothorax

Management at ER

• consult NS, ortho.• on foley, check urine routine• admit to ICU (NS)

Thanks for Your Attention!!!