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Case Conference

Case Conference. Int. 林美琪 96/04/03. Patient profile. 李  季 , 27y/o, male Chart num.:16897970 Admission to ER date: 96/03/30 04:36 Way of admission: 119 Discharge from ER date: 96/03/31 12:30. Injury mechanism.

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Case Conference

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  1. Case Conference Int.林美琪 96/04/03

  2. Patient profile • 李季, 27y/o, male • Chart num.:16897970 • Admission to ER date: 96/03/30 04:36 • Way of admission: 119 • Discharge from ER date: 96/03/31 12:30

  3. Injury mechanism • According to the inhabitant’s description, a great sound “bump” was heard. Falling down was suspected, but there is no witness. • 現場生命徵象: Coma(E1V1M1)

  4. Pre-hospital evaluation and management • sent to KMUH ER • Head: ILOC(+), dizziness(?), headache(?), nausea/vomiting(?), amnesia(?), vertigo(?) • Neck: pain(?), stiff(?), soreness(?) • Chest: pain(?), dyspnea(?) • Abdomen: pain(?), discomfort(?) • Limbs and skin : Bilateral forearm deformity, Right knee abrasion wound, Face deep laceration wound, Mandible deformity • 頸圈, 長背板固定, 左右手木板固定, 傷口包紮, 評估意識及生命跡象

  5. Initial evaluation (KMUH) A (airway) / B (breathing): • RR:20cpm, SpO2:70% • Collar fixation: need • Airway: respiration: not smooth airway obstruction sign: cyanotic and strider blood in the mouth trachea: mid-position breathing sound: bilateral rales

  6. C (circulation): • Rate: 64 bpm brachial a.: normal carotid a. : normal femoral a.: normal dorsalis pedis a.: normal • Cuff BP: 123/104 mmHg • Skin condition: appearance: not pale temp: warm (36.2’C) humidity: normal • Suspect: facial bone fracture and subcutaneous hematoma

  7. D (disable): • GCS: E1V1M1 • Pupil : od: 1mm, (-/-) os: 4mm, (-/-)

  8. E (exposure): • L’t face deep laceration (7cm) • L’t and R’t forearm deformity • R’t knee abrasions wound • No bruise over bilateral buttock and hip area • No urethra meatus bloody discharge

  9. Initial Resuscitation • On endotracheal tube (#7.5, fix 22cm) and assist ventilation • RR:24/min, TV:700ml, FiO2:40% • Maintain cardiac monitor • Insert 2 large-born IV line and rapid infusion of crystalloid solution (N/S and L/R) • On CVC • On foley and OG • Collect blood sample and urine routine for initial laboratory studies

  10. Initial Radiographic Studies • Brain CT (without contrast) • subarachnoid hemorrhage in left Sylvian fissure, left fronto-parietal regions and basal cistern • brain edema • skull base fracture • bilateral maxillary and mandible fracture • hemosinus in all paranasal sinuses • FAST : no intra-abdominal free fluid accumulation

  11. Left forearm AP and Lat X-ray • left distal radial and ulnar fracture, closed • Right forearm AP and Lat X-ray • Right knee AP and Lat X-ray • Right elbow AP and Lat X-ray • right humeral fracture, closed • Chest X-ray

  12. 12-Lead EKG • C-spine CT • Subarachnoid hemorrhage in the basal cistern and extending into cervical thecal sac. • Fractures of left posterior tubercle & left inferior articular facet of C6, left posterior tubercle of C7, left transverse process of T1, T2, and left 1st, 2nd ribs. • Pelvis CT • No image evidence of pelvic fracture

  13. Past history • IV drug abuser (heroin addiction) • DM (-) • HTN (-) • Hepatitis B or C carrier: denied • Op. hx.: denied • Allergy hx.: denied • Family hx.: non-contributory

  14. Lab data

  15. Tentative diagnosis • head injury /c skull base fracture /c traumatic SAH • bilateral maxillary and mandible fracture • right humeral fracture, closed • left distal radial and ulnar fracture, closed

  16. Ongoing Evaluation & Resuscitation • Monitor vital sign and conscious level • Evaluate the evidence of new or ongoing signs of shock • Antibiotics usage: cefazolin + GM • Keep patients warm • Consult NS: admitted to NS ICU for further care • Consult OW: casting the elbow and forearm fracture

  17. After admission • 03/31 PM4:35: BP drop and pulseless • Bosmin 1 Amp iv. • Dopamin 4 Amp + N/S 500ml Keep 30 ml/hr • Sigh DNR, then AAD

  18. Thanks for your attention!!

  19. maxillary fracture mandible fracture hemosinus

  20. Subarachnoid hemorrhage sphenoid bone (skull base) fracture Brain edema

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