Case presentation 96.09.04 Intern ???

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Case presentation96.09.04 Intern ???
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Personal profile

• Name ?O?
• Gender male
• Age 46 years old
• Chart number 16762291
• Arrival date at ED 96/08/20
• Time 0415 am

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Injury mechanism

• Suffered from a traffic accident with drunken
  state this morning (0400am) Suspect drunken
  driving
• ?????? drowsy and irritable (E3V3M4)
• CC Alcoholism with Traffic accident

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Pre-hospital evaluation and management

• Sent to KMUH ER by 119
• Head ILOC(?), dizziness(?), headache(?),
  nausea/vomiting(?), amnesia(?),
  vertigo(?)laceration wound over rt upper eyelid
  and earlobe
• Neck pain, stiff, soreness(?)
• Chest pain, dyspnea(?)
• Abdomen pain, discomfort(?)
• Limbs and skin abrasion wound over bil. knee

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AMPLE history

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

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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

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

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• 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 rt. upper eyelid(2 cm) and
  earlobe(1 cm)
• abrasion wound over bil. knee

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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)

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Lab data (96/08/20)
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Lab data (96/08/20)
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Chest x-ray
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Cervical spine X-ray
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Pelvis X-ray
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Plan

• Close observation with plaining brain CT study

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At 1605

• Consciousness coma GCS E1V1M1 Pupil size
  R/L3.5/2.0 with negative light reflex BP
  150/78 mmHg PR95/bpm.
• He was sent for emeregnt brain CT
• Emergent endotracheal intubation after Citosol
  sedation with paralytics (Genso)

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(No Transcript)
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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

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• 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.

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Post Operation

• 08/21, GCSE1 VE M2ICP was controled during
  1217mmHg, and glycerol was used.
• Fever up to 39?, Sputum () were noted.
  Antibiotics Cefazolin 1g iv q8h day 2
• Gentamicin

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• During 08/2208/24, 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 08/2608/28, persisted mild fever up to 39
  ? was noted. Follow up brain CT on 8/28 (1)
  Rt contusion hemorrhage with resolution and
• perifocal edema (2) previous left EDH
  had no enlargement

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• Remove ICP monitor on 08/28
• 08/29 fever subsided, remove endotracheal tube
• 08/30 Transfer to NS ward
• Q???ICU?????

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• Q?????????delay diagnosis?
• Q????????sedation???brain CT?

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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).

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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.

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Use of Intravenous Methohexital as a Sedative in
Pediatric Emergency Departments Hanan Sedik, MD
Arch Pediatr Adolesc Med. 2001155665-668

• 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.

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Current condition

• Admission to 7B 27-1
• GCSE2 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

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Thanks for attention
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Lerman B, Yoshida D, Levitt MA. A prospective
evaluation of the safety and efficacy of
methohexital in the emergency department. Am J
Emerg Med. 199614351-354.

• 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.