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
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: 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
Emergency department phase
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 >
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
PRIMARY ABCDE -Circulation
BP(RL): 129/80 mmHg Pulse: 105 beats/min Pulse assessment: not recorded Skin color assessment: pale<?>,cold<?>
PRIMARY ABCDE -Disability
AVPU: alert GCS score: E4V5M6 Pupil: not recorded
PRIMARY ABCDE -Exposure
left upper arm deformity Severe back pain with radiation to sternum
PRIMARY ABCDE –problems list
1.tachycardia 2.pain 3.left upper arm deformity
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
X-Ray <chest AP>
X-Ray <L’t arm>
Initial impression
1.right side hemothorax 2.left humeral fracture 3.tachycardia, r/o hemorrhage related
SECONDARY ABCDE- repeated general survey
1.AMPLE
2.Tubes and fingers in every orifice
3.Head to toe evaluation
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
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
12-lead EKG
The following conditions and managements
04:07BP:119/77 mmHg, HR:89bpm 04:40N/S 1BT ivd
arrange chest CT with and without
contrast
Chest CT
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
The following conditions and managements
06:00follow chest PA 06:30follow chest PA
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
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
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
Bedside cardiac echo
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
ER Initial diagnosis
1.right chest contusion hemorrhage 2.right hemopneumothorax 3.left humeral fracture 4.sternum fracture
Thanks for your attention!!