1. Case Conference Intern 陳姝蓉

2. Patient profile Name: 鍾高 O 錦 79 year-old female Occupation: unknown Chart number: 15790607 Arrival time: 2007.04.05 AM08:38 Arrival method: EMT from 小港 hospital

3. Injury mechanism The patient ingested unknown amount of hydrochloric acid at 6AM of April 5th She was brought to 小港 hospital ER for help

4. Pre-hospital evaluation and management Sent to 小港 hospital ER Consciousness: drowsy, GCS: E 2 V 2 M 4-5 Head : ILOC(-), dizziness(-), headache(-), nausea/vomiting(-), amnesia(-), vertigo(-) Mouth: oral ulcers (+) Neck: pain(-), stiff(-), soreness(-) Chest: pain(-), tachycardia(+) Abdomen: distension(+), tenderness(+) Extremities : edema(+)

5. Initial evaluation ( 小港 hospital) A (airway) / B (breathing):  Speech: incomprehensible sound  Respiration: SaO2: 88%  Lips: cyanotic and pale  Respiratory rate: 10~24/min C (circulation): Pulse: palpable over all major peripheral arteries Cuff BP : 122/80 mmHg Skin condition:  Appearance: pale and cyanotic over lips and mouth  Temperature: 35.7 C  Humidity: unknown

6. D (disability): GCS: E 2 V 2 M 4-5 Pupil response: od: 3mm, +/+ os: 3mm, +/+ E (exposure) : nil Initial evaluation ( 小港 hospital)

7. Progression at 小港 hospital Air hunger was noted with deterioration in GCS (E1V1M1)  Intubation with size 7.5 endotracheal tube fixed at 21 cm  On ventilator (TV: 500mL, RR: 16/min, FiO2: 100%)  On neck CVC and give N/S 1 bottle Blood pressure dropped to 81/57 mmHg  IV full-run  Consult surgeon

8. Due to peritonism, the patient was transferred to KMUH by ambulance

9. Initial evaluation (KMUH) A (airway) / B (breathing): Collar fixation: (-) Breathing:  Respiratory rate: on endo Airway:  Speech: incapable  Respiration: ambu-bagging  Airway obstruction sign: present  Foreign body in the mouth: absent  Trachea: midline

10. C (circulation): Pulse: impalpable on carotid artery Cuff BP : unmeasurable Skin condition:  Appearance: pale-looking  Temperature: cold (34.8C)  Humidity: unknown Initial evaluation (KMUH)

11. D (disability): GCS: E1VtM1 Pupil response: absent bilaterally E (exposure) : nil Initial evaluation (KMUH)

12. Current medication Unknown

13. Past history DM: (-), HTN: (+), Hepatitis: (-) Major depressive disorder? Smoking(-), alcohol(-), betal nut(-) Operation history: unknown Allergy history(-) Travel history(-), contact history(-)

14. Family history Not contributory

15. Secondary evaluation (KMUH ER) ECG monitor Lab data Pulse oximeter

16. Initial management Start CPR Fluid and drugs during resuscitation  NaHCO3  Atropine  Adrenaline  Gelofusine Lab  CBC, WBC classification, ABG, image Special management  DC shock  Ventilator

17. Lab data Blood96/04/05 WBC12.62 x 10 3 /uL RBC1.09 x 10 6 /uL Hgb3.5 g/dL Hct10.5 % MCV96.3 fL PLT45 x 10 3 /uL Neu66.9 % Eosin0.5 % Baso0.2 % Lymph30.7 % Mono1.7 % Arterial Blood Gas96/04/05 Temperature 37.0 ℃ pH7.207 pCO 2 24.5 mmHg pO 2 390.8 mmHg HCO 3 - 9.5 mmol/L Total CO 2 8.6 mmol/L Base excess-16.5 mmol/L SBC11.9 mmol/L BEecf-18.4 mmol/L %sO 2 c99.9 %

18. Image study

19. Impression Pulseless electrical activity (PEA) on arrival Corrosive esophagogastritis

20. Plans ACLS

21. Thanks for your attention !!!

22. Indication of surgical intervention for corrosive esophagogastritis Clinical signs of perforation, mediastinitis, or peritonitis