Case conferenceCase conference

Int. Int. 林鼎博林鼎博

EMT dataEMT data

• EMTEMT 抵達時間：抵達時間： 8/15 22:208/15 22:20• Trauma accidentTrauma accident （騎摩托車，遭廂型車撞擊後被壓在車（騎摩托車，遭廂型車撞擊後被壓在車

底）底）• AA ：尚可說話，以頸圈固定：尚可說話，以頸圈固定• BB ：： dyspneadyspnea ，， RR = 24RR = 24• CC ：： HR = 144HR = 144 ，， BP = 77 / 58BP = 77 / 58• DD ：： GCS = E4V5M6GCS = E4V5M6• EE ：頭部撕裂傷，雙大腿反曲於胸腹上，右大腿撕裂傷，左：頭部撕裂傷，雙大腿反曲於胸腹上，右大腿撕裂傷，左

大腿燙傷大腿燙傷

• Mask 10L/minMask 10L/min• 頸圈，夾板固定，長背板固定，止血頸圈，夾板固定，長背板固定，止血

Arrival dataArrival data

• 抵達時間：抵達時間： 8/15 22:438/15 22:43• AA ：呼吸平順，言語正常，需頸椎保護：呼吸平順，言語正常，需頸椎保護• BB ：： RR > 24 / minRR > 24 / min• CC ：： HR = 74HR = 74 ，， BP =84 / 55BP =84 / 55 ，末梢循環正常，末梢循環正常 SkinSkin ：冷，紅潤，溼度正常：冷，紅潤，溼度正常• DD ：： G4V5M6G4V5M6 ，， pupil = 3.0pupil = 3.0 ，， 3.0 reactive3.0 reactive• EE ：： Head Head laceration * 1.5cm laceration * 1.5cm 、、 avulsionavulsion Chest Chest contusion contusion Left forearm Left forearm laceration * 5cm laceration * 5cm Right thigh Right thigh avulsion avulsion Left thigh Left thigh burn ( 2 burn ( 2oo ，， 2%)2%) multiple abrasionmultiple abrasion

AMPLEAMPLE

• All deniedAll denied• Last mealLast meal ：： 6:00pm6:00pm

Initial assessment (1)Initial assessment (1)22:5622:56• AA ：： keep collarkeep collar ，， C-spine X-rayC-spine X-ray• BB ：： Chest PAChest PA ，，• CC ：： N/S 1 BTN/S 1 BT ，， L/R 1BTL/R 1BT• DD ：： Brain CT + C-spine CTBrain CT + C-spine CT• EE ：： Tetanus ToxoidTetanus Toxoid Pelvis X-rayPelvis X-ray Right knee X-ray (AP+lat)Right knee X-ray (AP+lat)• CBCCBC• GOT/GPTGOT/GPT ，， BUNBUN ，， CrCr ，， SugarSugar ，， NaNa ，， KK• PT / PTTPT / PTT

WBC 11.16

RBC 4.57

Hgb 14.1

Hct 44.1

MCV 96.5

MCH 30.9

MCHC 32

PLT 220

RDW-CV 12.1

RDW-SD 42.7

Sugar17

7

Urea N10.

1

Creatinine

1.33

Na14

2

K3.8

2

GOT12

8

GPT 90

PT P12.

8

PT C11.

1

PT(INR)1.2

5

PTT P31.

3

PTT C29.

1

23:0523:05

• N/S 1 BTN/S 1 BT• Fentanyl 0.1mgFentanyl 0.1mg• Penicillin testPenicillin test• Penicillin G 3MuPenicillin G 3Mu

23:0723:07

• 備 備 PRBC 4UPRBC 4U• Gelofusine 4% 1 BTGelofusine 4% 1 BT• Troponin I, CPK, CK-MBTroponin I, CPK, CK-MB

• ABO blood typingABO blood typing• Rh blood typingRh blood typing• Antibody screeningAntibody screening

• EthanolEthanol

CPK392

Tropo-I 0.02

CK-MB123

Ethanol 2.2

23:1023:10

• BP = 99/64 , PR = 127BP = 99/64 , PR = 127

23:1523:15

• Whole body CT (non enhanced) -- Whole body CT (non enhanced) -- holdhold

23:2123:21

• Wound treatmentWound treatment• FASTFAST ：：

– No pleural or pericardial effusion is foundNo pleural or pericardial effusion is found– Intraperitoneal cavityIntraperitoneal cavity ：： nilnil– Lung slicingLung slicing ：： presentpresent– Initial FAST surveyInitial FAST survey ：： npnp

• Blood gasBlood gas• EKG monitorEKG monitor• LactateLactate

pH7.2

7

pCO243.

9

pO254.

3

HCO3-19.

8

Total CO2

17.8

Base excess

-6.8

SBC18.

8

BEecf -7

%sO2c81.

9

Lactate 5.3

23:3023:30

• N/S 1 BTN/S 1 BT

• L/R 1 BTL/R 1 BT

23:4023:40

• BP = 115/56BP = 115/56 ，， PR = 162PR = 162• SpOSpO2 2 = 75%= 75%

23:50 23:50

• On chest tube (32#On chest tube (32# ，， fix 12cm)fix 12cm)• Consult Consult 骨科骨科

– Right pubicsuperior and inferior ramus fractureRight pubicsuperior and inferior ramus fracture– Right acetabulum posterior coloum fractureRight acetabulum posterior coloum fracture– Left femur neck fractureLeft femur neck fracture– PlanPlan ：： right leg skeletal traction, left leg skin tractiright leg skeletal traction, left leg skin tracti

on after condition stableon after condition stable• Consult Consult 泌尿科泌尿科

– Please consult again to survey GU trauma if conditiPlease consult again to survey GU trauma if condition is more stableon is more stable

• 開始輸開始輸 PRBC 2UPRBC 2U

23:5123:51

• BP = 90/51BP = 90/51 ，， PR = 163PR = 163• SpO2 = 74%SpO2 = 74%• Conscious clearConscious clear

00:0500:05

• BP = 79 / 54BP = 79 / 54 ，， PR = 84PR = 84• SpO2 = 58%SpO2 = 58%

• CitosolCitosol• On endo (7.5#On endo (7.5# ，， fix 21cm)fix 21cm)• 再接再接 PRBC 2UPRBC 2U

00:1500:15

• PRPR 量不到量不到

• CPR startCPR start• 0016 0016 NaHCO NaHCO33 4 amp 4 amp• 0017 0017 Adrenaline 1 amp Adrenaline 1 amp• 0020 0020 Adrenaline 1 amp Adrenaline 1 amp• 0023 0023 Adrenaline 1 amp Adrenaline 1 amp

• 0025 0025 HR =90 HR =90 ，， BP = 98/70BP = 98/70• CPR stopCPR stop

00:2500:25

• N/S 1 BTN/S 1 BT• On CVP with N/S 1 BTOn CVP with N/S 1 BT• 接接 ventilatorventilator ( TV = 600ml, Rate = 20, FiO( TV = 600ml, Rate = 20, FiO22 = 100%) = 100%)

00:3000:30

• 0030 0030 BP = 107/81 BP = 107/81 ，， PR = 65PR = 65 CVP level = 9 cmHCVP level = 9 cmH22OO EndoEndo 改改 23cm23cm

00:4500:45

• Recheck CxRRecheck CxR

00:5000:50

• 0050 0050 BP = 101/82 BP = 101/82 ，， PR=59PR=59 PRBC 2UPRBC 2U 輸畢輸畢• 0055 0055 BP = 96/76BP = 96/76 ，， PR = 69PR = 69 SpO2 = 75%SpO2 = 75% N/S 1 BTN/S 1 BT

01:0001:00

• BPBP 量不到，量不到， HR = 39HR = 39• CPR startCPR start• Adrenaline 1 ampAdrenaline 1 amp• 0105 0105 on 2nd chest tube at right side on 2nd chest tube at right side Emergent thoracotomy Emergent thoracotomy (ED thoracotomy with Clamshell incision)(ED thoracotomy with Clamshell incision) Adrenaline 1 ampAdrenaline 1 amp• 0108 0108 Adrenaline 1 amp Adrenaline 1 amp L/R 1 BTL/R 1 BT• 0111 0111 Adrenaline 1 amp Adrenaline 1 amp N/S 1 BTN/S 1 BT

01:1401:14

• 0114 0114 Adrenaline 1 amp Adrenaline 1 amp whole blood 2Uwhole blood 2U• 0117 0117 Adrenaline 1 amp Adrenaline 1 amp• 0120 0120 Adrenaline 1 amp Adrenaline 1 amp• 0123 0123 whole blood 2U whole blood 2U• 0126 0126 Adrenaline 1 amp Adrenaline 1 amp• 0127 0127 NaHCO NaHCO33 4 amp 4 amp• 0135 0135 Gelofusine 1 BT Gelofusine 1 BT BP 79/49BP 79/49 ，， PR = 142PR = 142• CPR stopCPR stop

01:4501:45

• BP = 50/30BP = 50/30 ，， PR = 150PR = 150• DopamineDopamine• UnasynUnasyn• Sent patient to ORSent patient to OR

In OR roomIn OR room01:4501:45• Clamshell incision was made for rapid access and bleeClamshell incision was made for rapid access and blee

ding control.ding control.• Manual cardiac massage was performed after the periManual cardiac massage was performed after the peri

cardiotomy was made. No pericardial effusion was nocardiotomy was made. No pericardial effusion was noted.ted.

• Active bleeding via huge laceration is found over RLL.Active bleeding via huge laceration is found over RLL.• Primary repair is performed via continuous suture.Primary repair is performed via continuous suture.• Dull response to our effort gradually developed!!Dull response to our effort gradually developed!!• Heart asystoleHeart asystole• 急救無效，急救無效， 04:0004:00 離開離開 OROR ，送回，送回 ERER

輸液整理 輸液整理 + + 大事紀大事紀• N/SN/S ：： 2256, 2305, 2330, 0025*2, 0055, 0111 (2256, 2305, 2330, 0025*2, 0055, 0111 ( 共共 3500cc)3500cc)• L/RL/R ：： 2256, 2330, 0118 (2256, 2330, 0118 ( 共共 1500cc)1500cc)• Gelo: 2307, 0135(Gelo: 2307, 0135( 共共 1000cc)1000cc)• PRBC = 2350*2 + 0005*2 (PRBC = 2350*2 + 0005*2 ( 共共 1000cc)1000cc)• Whole= 0114*2+0123*2(Whole= 0114*2+0123*2( 共共 1000cc)1000cc)• 總輸液量 總輸液量 = 8000 – 1850 = 6150cc= 8000 – 1850 = 6150cc

• 2243 2243 arrival arrival• 2340 2340 SpO2 = 75% SpO2 = 75%• 2350 2350 1st chest tube 1st chest tube• 0005 0005 SpO2 = 58% SpO2 = 58% ，， on endoon endo• 0015 0015 PR PR 量不到，量不到， 1st CPR1st CPR• 0100 0100 BP BP 量不到，量不到， PR=39PR=39 ，， SpO2 = 75%SpO2 = 75% 2nd CPR2nd CPR ，， 2nd chest tube2nd chest tube ， ， ED thoracotomy ED thoracotomy

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Thx for your attention!Thx for your attention!