Case report By 馮文翰

Identity / Name: 崔 X 誠 / Sex: male / Age: 29 years old / Chart number: / 來急診的時間： / Name: 崔 X 誠 / Sex: male / Age: 29 years old / Chart number: / 來急診的時間：

Chief complaint / Traffic accident on pm10:00, 8/11

Present illness / This 29 y/o male was well-being before. Unfortunately, he suffered from a traffic accident on 8/11. The mechanism of the trauma was a car crushing him from his back. His consious was lost since the accident. Then he was brought to 小港 Hosptial for help. / On the arrival of 小港 H, he was pulseless and GCS showed E1V1M1. The CPR was started and endotracheal tube was inserted there. Then, the resucitation was successful. And he was transferred to our ER after his condition was stable. / This 29 y/o male was well-being before. Unfortunately, he suffered from a traffic accident on 8/11. The mechanism of the trauma was a car crushing him from his back. His consious was lost since the accident. Then he was brought to 小港 Hosptial for help. / On the arrival of 小港 H, he was pulseless and GCS showed E1V1M1. The CPR was started and endotracheal tube was inserted there. Then, the resucitation was successful. And he was transferred to our ER after his condition was stable.

The status on arrival / Vital sign ： 85/42 mmHg, HR= 85/min, RR= 25/min with mechanical ventilator support, BT=36.3oC / Refer from 小港醫院： On Endo, NG, Foley / Coma scale ： E1VEM1 / Vital sign ： 85/42 mmHg, HR= 85/min, RR= 25/min with mechanical ventilator support, BT=36.3oC / Refer from 小港醫院： On Endo, NG, Foley / Coma scale ： E1VEM1

外院的診斷及處理 / Impression 1.frontal SDH 2.left tibial-fibular fx 3.pelvic fx 4.C1-2 fx, C6-7 dislocation 5.R/O internal bleeding / Impression 1.frontal SDH 2.left tibial-fibular fx 3.pelvic fx 4.C1-2 fx, C6-7 dislocation 5.R/O internal bleeding / Management: Atropine 1 amp Adrenaline 2 amp Pitressive 1 amp Gelofusine 2BT N/S 4 BT

Initial assessment / A(airway): Endo 外 on(7.5 Fr, fix 20cm) / B(breathing): 呼吸平順, chest symmetric expansion -->on ventilator: FiO2=100%, RR=16/min, Tidal volumn=560ml / C(circulation): BP=85/42 mmHg, Pulse rate=85 bpm -->N/S 500cc, Gelofusine 1 BT full run / D(defibrillation): no need / A(airway): Endo 外 on(7.5 Fr, fix 20cm) / B(breathing): 呼吸平順, chest symmetric expansion -->on ventilator: FiO2=100%, RR=16/min, Tidal volumn=560ml / C(circulation): BP=85/42 mmHg, Pulse rate=85 bpm -->N/S 500cc, Gelofusine 1 BT full run / D(defibrillation): no need

Focused history / A: denied / M: denied / P: nil / L: unknown / E: traffic accident / A: denied / M: denied / P: nil / L: unknown / E: traffic accident

Physical examination / Conscious: E1VeM1 / Pupil: L/R: 2.5mm/2.5mm, with symmetric light reflex / Sclera: not icteric / Neck: supple, LAP(-), JVD(-) / Chest: symmetric expansion BS: bilateral coarse HS: regular heart beat, no murmur / Abdomen: soft, / L/L: no pitting edema / Left elbow abrasion wound, right legs abrasion wound, left lower leg laceration and abrasion / Conscious: E1VeM1 / Pupil: L/R: 2.5mm/2.5mm, with symmetric light reflex / Sclera: not icteric / Neck: supple, LAP(-), JVD(-) / Chest: symmetric expansion BS: bilateral coarse HS: regular heart beat, no murmur / Abdomen: soft, / L/L: no pitting edema / Left elbow abrasion wound, right legs abrasion wound, left lower leg laceration and abrasion

Available Lab data / ABG pH=7.258 pCO2=44.6 pO2=370 HCO3=19.5 SaO2=99.9% / ABG pH=7.258 pCO2=44.6 pO2=370 HCO3=19.5 SaO2=99.9% / CBC & electrolyte WBC=11.67 RBC=4.72 Hgb=14.2 MCV=92.4 PLT=291 Na=139 K=4.4 BUN=12.3 CR=1.2 GOT=65 GPT=46

management / ABG / Abdominal CT -->r/o internal bleeding / C-spine AP + lateral CT / 12 lead EKG / 床頭抬高 (30 度 ) / Ice packing / On EKG monitor / NaHCO3 6 amp / PRBC 6 U / Platelet 12 U / N/S 1 BT / Gelofusin 1 BT / ABG / Abdominal CT -->r/o internal bleeding / C-spine AP + lateral CT / 12 lead EKG / 床頭抬高 (30 度 ) / Ice packing / On EKG monitor / NaHCO3 6 amp / PRBC 6 U / Platelet 12 U / N/S 1 BT / Gelofusin 1 BT

Image study

Impression at ER / Suspect neurologic shock with C1-2 fracture, and C6-7 dislocation / Head injury with frontal subdural hematoma / Pelvic fracture / Left tibial and fibular open fracture / Suspect neurologic shock with C1-2 fracture, and C6-7 dislocation / Head injury with frontal subdural hematoma / Pelvic fracture / Left tibial and fibular open fracture

Admission to NSICU / PRBC transfusion for acute blood loss (Hgb= 8.1) / Dopamine pump keep 30 ml/hr / IVF: Taita 3 N/S a.a / Closely monitor vital sign, GCS, and hemodynamics / Current antibiotic: Cefazolin + GM / PRBC transfusion for acute blood loss (Hgb= 8.1) / Dopamine pump keep 30 ml/hr / IVF: Taita 3 N/S a.a / Closely monitor vital sign, GCS, and hemodynamics / Current antibiotic: Cefazolin + GM

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