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Case presentation

Case presentation . Intern 8901066 凌永耀. Chief Complain . Right femoral, tibia and right forearm open fracture due to traffic accident . The status after the traffic accident. Hypovolemic shock( IV??): Heart rate> 140/min 脈搏壓變窄 BP down Respiratory rate??(>35/min)

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Case presentation

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  1. Case presentation Intern 8901066 凌永耀

  2. Chief Complain • Right femoral, tibia and right forearm open fracture due to traffic accident

  3. The status after the traffic accident • Hypovolemic shock( IV??): • Heart rate> 140/min • 脈搏壓變窄 • BP down • Respiratory rate??(>35/min) • Urine output?? on foley • Car vs Motorcycle. • Coma with neck collar • 固定護目位置: 右上肢，右下肢

  4. AMPLE history • Unknown!!

  5. ABCD 初步評估-AB • Airway / Breathing: • 需頸椎保護 • 氣道阻塞徵象:Respiratory effort • 氣道異物: 痰+口水 • 氣管正中 • Respiratory sound: bilateral decrease • Chest X-ray • R/O pneumothroax

  6. ABCD 初步評估-C • Circulation (shock?? ) • Pulse • Right side: pulseless ( fracture limb) • Left side: normal • Skin/ mucosa: pale • 骨折處持續出血: directly decompression • Adequate resuscitation: • blood pH=7.4 + U.O.= 0.5~1.0mL/kg.min

  7. 輸液 • Blood loss: • Lower leg: 1 Units (250~ 400 c.c.) • Femur: 2 units ( 500~800 c.c.) • Blood loss >750 c.c. • Warm IV fluid (large-bore intravenous line) • Crystalloid (N/S, L/R)  L/R 1 BT • Colloid • Blood (SBP<90 or SBP<110+ PR>140)

  8. ABCD 初步評估-D • Disability ( intracranial or spinal origin??) • GCS score: E1V1M2  need early intubation • Pupils: sluggish right =5mm; left =3mm • Uncal herniation  壓到E-W nucleus ??

  9. 1700 BP 80/41 PR 128 • 輸注 whole blood 4U<1700 no1, 1705 no2> • Citosol push 5 ml • On CVP<BP 121/87, PR 136, CVP 8cmH2O> • Consult 骨科 1610 BP 102/ 85 1600 at arrival BP 112/90 • On ventilator <TV 500ml, RR 16/min, FiO2 100% • 領 Whole blood 8U • 止血: Wound treatment with air splint x 2 • Abdominal echo <1640> • On O2 • On ECG monitor • L/R 1 bot • Blood exam • Citosol 6 ml iv • Citosol 4 ml iv • On endo 7.5 Fr. Fix 22 cm

  10. 1730 BP 80/41 PR 128 1755 BP104/80 PR 170 SpO2= 100%, CVP=3cmH2O • 輸注 whole blood 4U<1730 no3> • Cefazoline 1g+ GM 80mg/ 2ml • N/S 1000cc • 借 4U PRBC • 輸血完畢，無不良反應 • L/R 1 BOT • Admitted to 7ES22-19 and send to OR at 1810

  11. Plans • Chest: AP • Pelvis: AP • Hand: AP+ R • Forearm: AP+ R • Humur: AP+ R • Foot: AP+ R • Low leg: AP+ R • Femur: AP+ R • CT scan • For Brain (without contrast) • For C-spine (without contrast) • CBC • GOT/GPT BUN Cr • Sugar Na K • PT/PTT • Ethanol • ABG • Urine routine • CK CK-MB • Troponin-I

  12. Available laboratory data(0604)

  13. Locate the bleeding

  14. Echo ( FAST) • Lung sliding: + no OPTX • Negative finding for E-FAST

  15. Radiography- X ray

  16. Chest on 0604 1) No active cardiopulmonary disease. 2) Status post insertion of the endotracheal tube

  17. Pelvis AP view

  18. Right femur AP View • Impression： Comminuted fracture at right middle femoral shaft with displacement.

  19. Right lower leg AP and Lateral Views • Impression： Fractures at right middle tibial and fibular shafts.

  20. Right foot lateral View • Impression： Fracture at the right 1st metatarsal bone.

  21. CT on brain on 0604

  22. LeFort I fracture

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