Case Presentation

1
Case Presentation

• Presenter 8901157 Intern ???

2
Brief History referred from ??

• Male
• 54y/o
• 07431690
• Conscious clear??, E4V5M5
• 1200 TA
• close pelvic fracture
• ???, ??,??,?? ???????

• ??6600 cc fluid
• 1 2-way CVP line
• 1. PRBC 1U
• 2. Gelofusin 1 BT
• 2 peripheral line
• right hand IV with N/S
• right foot iv with N/S

3
1st assessment (950817 1438)

• Airway
• patent
• no need neck protect
• Can talk
• Breathing10-24
• obstruction nil
• foreignnil
• tracheal deviation nil

• Circulation 74/40
• skin pale
• temperature warm
• moist normal
• Pulsenormal
• Bleeding ??
• Disability
• E3V5M6 GCS14
• Expose / Enviroment

4
2nd assessment

• Allergy nil
• Medication ??
• Past illness??
• Last meal 950817 1200
• Events Traffic accident, crushing injury
• ??H suggest angiography
  embolization
• General survey
• Left ant face , chest, left upper limbs lower
  limbs open wound, no active bleeding

5
Initial management

• Pelvic fracture
• Force?
• ??-pelvic unstable threatening hypotension
• ??- bladder ureter injury
• ??- pelvic unstable
• Volume status
• 6600cc in about lt 3hr
• Hypovolemic status
• Fluid resuscitation
• 31 crystaloid blood loss
• Crushing injurygt31(more crystaloid)
• Progressive bleeding lt31 (more blood)

• 1440
• O2 4L/min
• blood exam
• n/s 1000ml ivd
• on EKG monitor
• On oxymeter
• ??
• PRBC 6U
• FFP 6U
• PLT 12U
• 1457
• arrange angiography, sign permit
• 1440
• SaO2 94
• 1500
• BP 95/50 p90
• N/S 1 BT
• 1515
• BP 84/38, p88

6
?? lab data

• WBC 6280/ul
• RBC 5.2
• HGB 15.4
• HCT 45.9
• PLT 184
• PT P/PT C 11.9 / 10.7
• PTT P/ PTT C 28.7 / 1.65

• GOT/GPT 31/29
• BUN/CREA 22.8/1.65
• NA/K137/3.8
• GLU 245

7
1440 blood exam

• Distal upper limb 150-250
• Proximal upper limb 250
• Distal lower limb 500
• Proximal lower limb 1000
• Pelvic 1500-3000

8
??CT
9
Angiography embolization
10
angiography

• The aortogram, bilateral internal iliac
  arteriography reveal extravasation via the left
  superior gluteal artery.

11
2nd management --back from angio room --
continue bleeding

• 1720 consult OW
• whole blood 10 U
• 1740
• BP 112/78 P102
• PRBC 2U ???
• DOPAMINE 2 amp N/S 1 BT keep 10 gtt/min
• 1810
• P RBC 2
• BP121/76 P102
• FFP 2U 2
• P RBC 2
• 1850
• N/S 1BT transamine 1 amp
• 1905
• BP 109/72 P103 Sao2 100

12
2nd management --back from angio room --
continue bleeding

• 1910
• sign permit
• NPO
• N/S 1 Bt trasamine 2amp IVD
• chest-x-ray PA view
• 1930 BP 107/59 PR 101
• 2010 BP 99/59 P102
• 2035
• BP 98/53 P120
• SaO2100
• 2040
• blood exam
• ABD CT enhanced
• 2050
• sent p't to CT room
• 95/50 P128 Sao2 100

• Source of bleeding ??
• Open wound
• ???
• ??
• ??
• ??

13
Image 2

• Chest x-ray
• Abdomen CT
• CBC

14
(No Transcript)
15
(No Transcript)
16
(No Transcript)
17
(No Transcript)
18
3th management -- prepare to OR

• 2110
• BP 120/55 P130
• SaO2 100
• PLT ?????
• 2112
• sinus tachycardia
• 2115
• whole blood
• consult GS
• 2130
• 97/62 P68 Sao2 100
• non-rebreathing mask use 10 L/min

19
3th management -- prepare to OR

• 2135
• s dyspnea Sao2 100
• On endo
• citosol aq dest1amp--gt5u iv
• on endo fix 23cm
• PRN surgeon
• on ventilator TV 600ml rate 8 times/min
• 2142
• EKG sinus tachycardia
• 2200
• BP104/69 PR118
• whole Blood
• 2215
• BP101/69 PR138
• sent to OR 15ESI 1-8

• On endo

20
OR

• splenectomy

21
Impression

• Pelvic fracture
• Hypovolemic shock
• Spleen laceration
• Left Kidney parechyma injury
• Mixed type acidosis, metabolic acidosis
  respiratory acidosis

22
Thanks for your attention ?
23
(No Transcript)