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Case presentation 96.09.04 Intern 胡學錦

Case presentation 96.09.04 Intern 胡學錦. Personal profile. Name : 吳 O 民 Gender : male Age : 46 years old Chart number : 16762291 Arrival date at ED : 96/08/20 Time : 04:15 am. Injury mechanism.

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Case presentation 96.09.04 Intern 胡學錦

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  1. Case presentation96.09.04Intern 胡學錦

  2. Personal profile • Name : 吳O民 • Gender : male • Age : 46 years old • Chart number : 16762291 • Arrival date at ED : 96/08/20 • Time : 04:15 am

  3. Injury mechanism • Suffered from a traffic accident with drunken state this morning (04:00am) Suspect drunken driving • 現場生命現象: drowsy and irritable(E3V3M4) • CC: Alcoholism with Traffic accident

  4. Pre-hospital evaluation and management • Sent to KMUH ER by 119 • Head :ILOC(?), dizziness(?), headache(?), nausea/vomiting(?), amnesia(?), vertigo(?)laceration wound over r’t upper eyelid and earlobe • Neck: pain, stiff, soreness…(?) • Chest: pain, dyspnea…(?) • Abdomen: pain, discomfort…(?) • Limbs and skin : abrasion wound over bil. knee

  5. AMPLE history • Allergies: unknown • Medication: unknown • Past illness: • DM:(?) • HTN:(?) • Other systemic diseases(?) • Operation history(?) • Last Meal : (?)

  6. Initial evaluation (KMUH) A (airway) / B (breathing): • Collar fixation: (+) • Airway: speech: (?) respiration: smooth • airway obstruction sign (-) • foreign body in the mouth (-) • Trachea • Breathing sound: clear

  7. C (circulation): • Rate: brachial a. , carotid a., femoral a. , dorsalis pedis a. • Cuff BP : 105/45 mmHg • Skin condition: appearance, temperature, humidity

  8. D (disable): • GCS: E2V2M5 • Pupil response: od: 2 mm os: 2 mm E ( exposure ) : • abrasion wound over nose and bil. maxillary area, • laceration wound over r’t. upper eyelid(2 cm) and earlobe(1 cm) • abrasion wound over bil. knee

  9. Secondary evaluation (KMUH ER) • Chest X-ray AP & lateral view • Cervical spine X-ray AP & lateral view • Pelvis X-ray AP • Brain CT without contrast (due to drowsy consciousness and irritable state, brain CT was hold for safety concern)

  10. Lab data (96/08/20)

  11. Lab data (96/08/20)

  12. Chest x-ray

  13. Cervical spine X-ray

  14. Pelvis X-ray

  15. Plan • Close observation with plaining brain CT study

  16. At 16:05 • Consciousness: coma GCS: E1V1M1Pupil size: R/L:3.5/2.0 with negative light reflex BP: 150/78 mmHg PR:95/bpm. • He was sent for emeregnt brain CT • Emergent endotracheal intubation after Citosol sedation with paralytics (Genso)

  17. Tentative diagnosis • Traumatic ICH and SDH with mass effect and midline shift • Alcoholism addition • r/o C- spine injury • Left ear lobe laceration (1cm) • Facial laceration (2 cm) • Abrasion wound over bilateral knees

  18. Under the impression of traumatic ICH and SDH with mass effect and midline shift, N/S was consult and he was sent to OR for emergent right craniectomy, SDH & ICH removal and ICH monitor insertion. • Then, he was admitted to 7ENI-31 for further therapy.

  19. Post Operation • 08/21, GCS:E1 VE M2ICP was controled during 12~17mmHg, and glycerol was used. Fever up to 39℃, Sputum (+) were noted. Antibiotics: Cefazolin 1g iv q8h day 2 Gentamicin

  20. During 08/22~08/24, spiking fever up to 40 ℃ was noted. • 08/25: The sputum culture collected on 8/22 showed Pseudomonas aeruginosa, and antibiotics shifted to Tazocin 2 vial q8h. • During 08/26~08/28, persisted mild fever up to 39 ℃ was noted. Follow up brain CT on 8/28: (1) R’t contusion hemorrhage with resolution and perifocal edema (2) previous left EDH had no enlargement

  21. Remove ICP monitor on 08/28 • 08/29: fever subsided, remove endotracheal tube • 08/30: Transfer to NS ward Q:無法出ICU之併發症?

  22. Q:留觀待醒過程是否易delay diagnosis? Q:酒後躁動患者是否sedation後去做brain CT?

  23. Approach to neuroimaging in children 2007 UpToDate • Sedation — Sedation is rarely required for CT examinations in children because most CT examinations take only seconds or minutes to perform, particularly when ultrafast helical/spiral or multidetector/multislice technology is used. • High-resolution studies that require immobilization to avoid motion artifact (eg, temporal bone examination) are the exception. A newborn or young infant often can be examined during sleep (eg, after a feeding or at the usual nap-time).

  24. Hepatic trauma: CT findings and considerations based on our experience in emergency diagnostic imagingEuropean Journal of RadiologyVol: 50 Issue: 1, April, 2004  p: 59-66 • In the case of non cooperative patients, presenting with neurological signs, sedation may be required and also assisted ventilation eventually, with continuous monitoring of cardiac and respiratory parameters.

  25. Use of Intravenous Methohexital as a Sedative in Pediatric Emergency Departments Hanan Sedik, MDArch Pediatr Adolesc Med. 2001;155:665-668 • Methohexital has been used in adult emergency departments and has been found to produce rapid and brief sedation, especially for orthopedic procedures. • Lerman et al studied 76 adult patients in a prospective observational study where IV methohexital had been used for a variety of procedures, and concluded that it caused clinically insignificant changes in hemodynamics and oxygenation. Although respiratory depression did occur, if significant it was brief and easily managed. • Zink et al reported a consecutive case series of 102 patients (including 10 patients younger than 10 years) who received IV methohexital for various procedures. The authors concluded that methohexital is safe and effective in selected emergency department patients.

  26. Current condition • Admission to 7B 27-1 • GCS:E2 V2 M3 • BP: 109/78 mmHg • Pupil: R 2.5mm L 2.5mm, bilateral prompt reflex • MP R L upper limb 2 1 lower limb 2 2 • Plan : 1. keep Saxizon 100mg iv q8h second day due to bilateral bronchus wheezing 2. Antibiotics: Tazocin 2 vial iv q8h day 9 3. Consult rehabilitation department

  27. Thanks for attention~

  28. Lerman B, Yoshida D, Levitt MA. A prospective evaluation of the safety and efficacy of methohexital in the emergency department. Am J Emerg Med. 1996;14:351-354. • MTX caused clinically insignificant changes in hemodynamics or oxygenation, although respiratory depression did occur; significant respiratory depression was brief and easily managed. MTX provided rapid and excellent levels of sedation with little or no patient recall or pain.

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