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Case conference

Case conference. Int. 林鼎博. EMT data. EMT 抵達時間： 8/15 22:20 Trauma accident （騎摩托車，遭廂型車撞擊後被壓在車底） A ：尚可說話，以頸圈固定 B ： dyspnea ， RR = 24 C ： HR = 144 ， BP = 77 / 58 D ： GCS = E4V5M6 E ：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 Mask 10L/min 頸圈，夾板固定 ，長背板固定， 止血. Arrival data. 抵達時間： 8/15 22:43

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Case conference

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  1. Case conference Int. 林鼎博

  2. EMT data • EMT抵達時間：8/15 22:20 • Trauma accident（騎摩托車，遭廂型車撞擊後被壓在車底） • A：尚可說話，以頸圈固定 • B：dyspnea，RR = 24 • C：HR = 144，BP = 77 / 58 • D：GCS = E4V5M6 • E：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 • Mask 10L/min • 頸圈，夾板固定，長背板固定，止血

  3. Arrival data • 抵達時間：8/15 22:43 • A：呼吸平順，言語正常，需頸椎保護 • B：RR > 24 / min • C：HR = 74，BP =84 / 55，末梢循環正常 Skin：冷，紅潤，溼度正常 • D：G4V5M6，pupil = 3.0，3.0 reactive • E：Head  laceration * 1.5cm、avulsion Chest  contusion Left forearm  laceration * 5cm Right thigh  avulsion Left thigh  burn ( 2o，2%) multiple abrasion

  4. AMPLE • All denied • Last meal：6:00pm

  5. Initial assessment (1)22:56 • A：keep collar，C-spine X-ray • B：Chest PA， • C：N/S 1 BT，L/R 1BT • D：Brain CT + C-spine CT • E：Tetanus Toxoid Pelvis X-ray Right knee X-ray (AP+lat) • CBC • GOT/GPT，BUN，Cr，Sugar，Na，K • PT / PTT

  6. 23:05 • N/S 1 BT • Fentanyl 0.1mg • Penicillin test • Penicillin G 3Mu

  7. 23:07 • 備 PRBC 4U • Gelofusine 4% 1 BT • Troponin I, CPK, CK-MB • ABO blood typing • Rh blood typing • Antibody screening • Ethanol

  8. 23:10 • BP = 99/64 , PR = 127

  9. 23:15 • Whole body CT (non enhanced) -- hold

  10. 23:21 • Wound treatment • FAST： • No pleural or pericardial effusion is found • Intraperitoneal cavity：nil • Lung slicing：present • Initial FAST survey：np • Blood gas • EKG monitor • Lactate

  11. 23:30 • N/S 1 BT • L/R 1 BT

  12. 23:40 • BP = 115/56，PR = 162 • SpO2 = 75%

  13. 23:50 • On chest tube (32#，fix 12cm) • Consult 骨科 • Right pubicsuperior and inferior ramus fracture • Right acetabulum posterior coloum fracture • Left femur neck fracture • Plan：right leg skeletal traction, left leg skin traction after condition stable • Consult 泌尿科 • Please consult again to survey GU trauma if condition is more stable • 開始輸PRBC 2U

  14. 23:51 • BP = 90/51，PR = 163 • SpO2 = 74% • Conscious clear

  15. 00:05 • BP = 79 / 54，PR = 84 • SpO2 = 58% • Citosol • On endo (7.5#，fix 21cm) • 再接PRBC 2U

  16. 00:15 • PR量不到 • CPR start • 0016  NaHCO3 4 amp • 0017  Adrenaline 1 amp • 0020  Adrenaline 1 amp • 0023  Adrenaline 1 amp • 0025  HR =90，BP = 98/70 • CPR stop

  17. 00:25 • N/S 1 BT • On CVP with N/S 1 BT • 接ventilator ( TV = 600ml, Rate = 20, FiO2 = 100%)

  18. 00:30 • 0030  BP = 107/81，PR = 65 CVP level = 9 cmH2O Endo改23cm

  19. 00:45 • Recheck CxR

  20. 00:50 • 0050  BP = 101/82，PR=59 PRBC 2U輸畢 • 0055 BP = 96/76，PR = 69 SpO2 = 75% N/S 1 BT

  21. 01:00 • BP量不到，HR = 39 • CPR start • Adrenaline 1 amp • 0105  on 2nd chest tube at right side Emergent thoracotomy (ED thoracotomy with Clamshell incision) Adrenaline 1 amp • 0108  Adrenaline 1 amp L/R 1 BT • 0111  Adrenaline 1 amp N/S 1 BT

  22. 01:14 • 0114  Adrenaline 1 amp whole blood 2U • 0117  Adrenaline 1 amp • 0120  Adrenaline 1 amp • 0123  whole blood 2U • 0126  Adrenaline 1 amp • 0127  NaHCO3 4 amp • 0135  Gelofusine 1 BT BP 79/49，PR = 142 • CPR stop

  23. 01:45 • BP = 50/30，PR = 150 • Dopamine • Unasyn • Sent patient to OR

  24. In OR room01:45 • Clamshell incision was made for rapid access and bleeding control. • Manual cardiac massage was performed after the pericardiotomy was made. No pericardial effusion was noted. • Active bleeding via huge laceration is found over RLL. • Primary repair is performed via continuous suture. • Dull response to our effort gradually developed!! • Heart asystole • 急救無效，04:00離開OR，送回ER

  25. 輸液整理 + 大事紀 • N/S：2256, 2305, 2330, 0025*2, 0055, 0111 (共3500cc) • L/R：2256, 2330, 0118 (共1500cc) • Gelo: 2307, 0135(共1000cc) • PRBC = 2350*2 + 0005*2 (共1000cc) • Whole= 0114*2+0123*2(共1000cc) • 總輸液量 = 8000 – 1850 = 6150cc • 2243  arrival • 2340  SpO2 = 75% • 2350  1st chest tube • 0005  SpO2 = 58%，on endo • 0015  PR量不到，1st CPR • 0100  BP量不到，PR=39，SpO2 = 75% 2nd CPR，2nd chest tube， ED thoracotomy

  26. 照片

  27. Thx for your attention!

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