Case presentation

1
Case presentation

• Intern 8901066 ???

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Chief Complain

• Right femoral, tibia and right forearm open
  fracture due to traffic accident

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The status after the traffic accident

• Hypovolemic shock( IV??)
• Heart rategt 140/min
• ?????
• BP down
• Respiratory rate??(gt35/min)
• Urine output??? on foley

• Car vs Motorcycle.
• Coma with neck collar
• ?????? ???,???

Respiratory Blood pressure Pulse rate Temperature
16/min 112/90 mmHg 167/min 35.4 C
4
AMPLE history

• Unknown!!

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ABCD ????-AB

• Airway / Breathing
• ?????
• ??????Respiratory effort
• ???? ???
• ????
• Respiratory sound bilateral decrease
• Chest X-ray
• R/O pneumothroax

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ABCD ????-C

• Circulation (shock?? )
• Pulse
• Right side pulseless ( fracture limb)
• Left side normal
• Skin/ mucosa pale
• ??????? directly decompression
• Adequate resuscitation
• blood pH7.4 U.O. 0.51.0mL/kg.min

7
??

• Blood loss
• Lower leg 1 Units (250 400 c.c.)
• Femur 2 units ( 500800 c.c.)
• Blood loss gt750 c.c.
• Warm IV fluid (large-bore intravenous line)
• Crystalloid (N/S, L/R) ? L/R 1 BT
• Colloid
• Blood (SBPlt90 or SBPlt110 PRgt140)

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ABCD ????-D

• Disability ( intracranial or spinal origin??)
• GCS score E1V1M2 ? need early intubation
• Pupils sluggish right 5mm left 3mm
• Uncal herniation ? ??E-W nucleus ??

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1610 BP 102/ 85
1600 at arrival BP 112/90

1. On ventilator ltTV 500ml, RR 16/min, FiO2 100
2. ? Whole blood 8U
3. ?? Wound treatment with air splint x 2
4. Abdominal echo lt1640gt

1. On O2
2. On ECG monitor
3. L/R 1 bot
4. Blood exam
5. Citosol 6 ml iv
6. Citosol 4 ml iv
7. On endo 7.5 Fr. Fix 22 cm

10
1730 BP 80/41 PR 128
1755 BP104/80 PR 170 SpO2 100, CVP3cmH2O

1. ?? whole blood 4Ult1730 no3gt
2. Cefazoline 1g GM 80mg/ 2ml
3. N/S 1000cc
4. ? 4U PRBC

1. ????,?????
2. L/R 1 BOT
3. Admitted to 7ES22-19 and send to OR at 1810

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Plans

• CBC
• GOT/GPT BUN Cr
• Sugar Na K
• PT/PTT
• Ethanol
• ABG
• Urine routine
• CK CK-MB
• Troponin-I

• Chest AP
• Pelvis AP
• Hand AP R
• Forearm AP R
• Humur AP R
• Foot AP R
• Low leg AP R
• Femur AP R
• CT scan
• For Brain (without contrast)
• For C-spine (without contrast)

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Available laboratory data(0604)
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Locate the bleeding
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Echo ( FAST)

• Lung sliding no OPTX
• Negative finding for E-FAST

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Radiography- X ray
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Chest on 0604
1) No active cardiopulmonary disease. 2)
Status post insertion of the endotracheal tube
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Pelvis AP view
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Right femur AP View

• Impression
  Comminuted fracture at right
  middle femoral shaft with displacement.

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Right lower leg AP and Lateral Views

• Impression
  Fractures at right middle
  tibial and fibular shafts.

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Right foot lateral View

• Impression
  Fracture at the
• right 1st metatarsal
• bone.

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CT on brain on 0604
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LeFort I fracture
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Initial diagnosis at ER

1. Blunt head trauma (brain concussion)
2. Blunt thoracic trauma with BCI( blunt cardiac
   injury)
3. Multiple fractures (right forearm, right lower
   limb, and right foot)
4. Facial bone fracture, right IMC maxillary
   fracture
5. r/o left wrist contusion with fracture

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Chest x ray on 0605

1. Pneumomediastinum, soft tissue emphysema over
   bilateral neck and chest wall.
2. Status post insertion of the endotracheal tube,
   NG tube and bilateral subclavian central lines.

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CT on 0610

• Low density over right cerebral hemisphere
• Ventricular compression
• Mid-line shift
• Impression acute CVD at right hemisphere favor
  trauma related( fatty emboli may be considered

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Thanks a lot!!