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Case presentation

This case report documents a traumatic injury involving severe open fractures of the right femur, tibia, and forearm due to a motorcycle accident. The patient presented with hypovolemic shock characterized by tachycardia, hypotension, and altered mental status. Emergency management included airway protection, fluid resuscitation, and monitoring of vital signs. An initial assessment revealed significant blood loss and the necessity for surgical intervention. Imaging studies indicated comminuted fractures and potential intracranial injury. The case underscores the critical nature of rapid assessment and intervention in trauma patients.

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Case presentation

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Presentation Transcript

  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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