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ER / Case Presentation
Int 陳姿吟
Patient Profile 49 y/o male Admitted Date: 95/10/11 15:18
Pre-hospital phase Transferred from 輔英 H Assessment : R/O organophosphates intoxication Head injury Management : On endotracheal tube brain CT C-spine AP, lateral 、 CXR 、 Pelvic X ray right leg X ray On NG→ green liquid N/S : 2000ml
toxoid Atropine
Emergency Department Phase 10/11 15:18
Primary ABCDE Airway
On endotracheal tube Breathing
RR : 10-24/minbreathing sound : ?SpO2 : ?
CirculationBP : 176/82 mmHg
PR : 75 /min
Primary ABCDE
DisabilityGCS : E2VeM2-3
Light Reflex : ±/±, 1/1
Exposure/ EnvironmentBT: 35℃
Epistaxis Abrasion wound : 2cm*2cm on the forehead 4cm*4cm on the right chest wall 10cm*2cm on the right knee
Problem List
BP : 176/82 mmHg GCS : E2VeM2-3
Light Reflex : ±/±, 1/1 Breathing : Right upper lung lobe collapse
→ ? foreign body underestimate on CXR
Multiple abrasion wounds, epistaxis On NG→ green liquid
Initial Management On ventilator : TV 600ml, RR18/min, FiO2 100 ,﹪ A/C mode EKG, Pulse Oximeter Lab
Brain CT at 輔英 H
Chest PA at 輔英
C-spine at 輔英
Pelvic
Right leg
Data WBC : 3360 RBC : 5.66x106 Hb : 15.4 Hct : 48.3 Plt : 257 BUN/CREA : 13.5/1.51 Na/K : 142/3.05 GOT/GPT : 94/87 Ca++ : 4.85 PT : 9.7/11.1 INR : 0.79 aPTT : 26.8/29.2
• Sugar 329
• CRP 0.28
• Ammonia 94
• Ethanol 2.3
• Cholinesterase 338
• Paraquat test negative
• urine BZD 369.60
ABG:
pH 7.141
PCO2 63
PO2 68.4
HCO3- 21
Base excess –9
﹪O2sat 85.1﹪
Initial Impression
Consciousness disturbance
r/o organophosphates intoxication, BZD over dose Right upper lung lobe collapse
foreign body induced, r/o tooth
Secondary ABCDE
16:00 BP 178/88 PR: 73 SpO2: 87﹪ 16:30 BP 173/87 PR: 75 SpO2: 86﹪
AMPLE Tubes and fingers in every orifice Head to toe evaluation
Following Conditions and Managements 16:30 arrange brain CT with enhancement
chest CT with enhancement
C-spine CT with enhancement
Brain CT
C-spine CT
Chest CT
16:50 BP158/88, PR 88, SpO2 89﹪ 17:10 BP170/86, PR 86
E1VeM1
urine output : 450ml
NG 250c.c, green
management : N/S 1 bot
PAM 10 Amp keep 20gtt/min
18:30 BP168/88, PR 89, SpO2 88﹪ E2VeM2-3
management : N/S 1 bot 18:40 pupil size: pin point(ou)
check 12 lead EKG
轉內科 20:15 BP151/96, PR 96, SpO2 87﹪ 轉內科 ICU
10/11 On CVC E1VeM1 10/12 E1VeM1
Arrange bronchoscope
to remove foreign body
10/12 E1VeM1
poor urine amount
liver function downhill( GOT/GPT 6945/6405,
PT INR 2.18)
DIC profile : FDP ( - ) , fibrinogen 247
D-dimer 457
thrombocytopenia
10/13 E1VeM1
Hepatoglobin 51.8
BUN/Cr 51.8/5.77
Cholinesterase 448
TCA < 0.1
PLT 9000/ul
Thanks for your Attention!