R3 吳師豪/ 鍾亢主任/邱德發主任 2010/08/31 Chart No:4978433 ED/ICU M&M conference R3 吳師豪/ 鍾亢主任/邱德發主任 2010/08/31 Chart No:4978433

In KER 2010/07/26 14:00左右 突然由急診大門傳來尖叫與喧鬧聲… 接著推入一男童…歲數不明約七、八歲 臉色蒼白，呼吸淺弱… 立刻上前壓胸，右鎖骨處噴出鮮血… 一條鋼筋約50公分，置於右側床邊

Triage 姓名: XXX 性別: 男 童 年齡: ?? y/o 到院方式: 自家車 到院時間: 2010/07/26 14:05 Vital signs: T:35.4 P:155 R:24 SBP:0 DBP:0 E:1 V:1 M:1 檢傷級數: 1 級 主訴 :  病患來診為胸部穿刺傷,被鐵條插入，由工地工人送入，工人訴從三樓摔下。 3

PAT Appearance Breath Acute ill -looking shallow Circulation pale, cyanosis

Present illness 在鄰居家玩，Falling from 3rd floor，樓下是工地 Neck stabbed by an iron bar, Active bleeding and send in by 工地工人 Loss of cons at scene

小兒重傷病患，你該如何急救? What would you do now?

ATLS primary survey ABCDE primary resuscitation Quick Hx （AMPLE） Secondary ABCDE

PRIMARY SURVEY (Assessment and Management) A ： Airway + C-spine  B ： Breathing + O2 C ： Circulation + Haemostasis  D ： Disability ( AVPU + pupils) E ： Exposure + environment F ： filums of C-spine, chest and pelvis G ： Gastric tube and Foley 

Further detail problems Intubation or not? RSI or not? Medication ? dose? 患者年紀? 體重? Size of Trachea tube? Depth ? Fluid challenge? Amount?

Indications of intubation Control IICP PaCO2 : 25-30 mmHg Respiratory failure CPR, flail chest, severe shock Obtain airway Potential of airway compromise (e.g. gunshot) Protect airway Aspiration risk, thermal / caustic airway burn

ATLS. Student course manual . 8th Ed, 2008

Contraindication of Atropine glaucoma, pyloric stenosis prostatic hypertrophy except in doses ordinarily used for preanesthetic medication. life-threatening poisoning by organophosphorous nerve agents and insecticides

Ped. ATLS (1) Cuffed tubes ETT sizes NO cuffs < 8yo b/c of narrow cricoid ring provides “functional cuff” ETT sizes Age/4 + 4 Size of nostril, or 5 th finger Have size above and size below available

Ped. ATLS (2) Blade sizes Depth 0 - 2 y Miller 1 2 - 10 y Miller/Mac 2 > 10y  Mac 3 Depth ETT size (i.d.) X 3 Age/2 +12 Vocal cord marker

Ped. ATLS (3) Fluid boluses: 20 cc/kg (compared to 2L in adults) x 3 then 10cc/kg/hr Blood transfusion: 10 cc/kg Broselow tape essential equipment Intraosseous or venous cutdown if can’t get iv access (3Xs or 90sec)

Ped. ATLS (4) Increased emphasis on gastric decompression  poor ventilation and vagal stimulation Hypothermia bigger issues in kids: make sure iv fluids warmed, blankets, etc

Quick Hx （AMPLE） A ：allergy M ：medication P ：past Hx, pregnancy L ：last meal E ：event / environment related to injury

SECONDARY SURVEY 頭：deform?Bleeding?(耳鼻喉) 頸：neck veins , trachea, hematoma 胸：BS, paradoxical movement, bruises 腹：Soft? Distend? Pelvis stability? FAST 四肢：Defom? Pulse? Motor? Sensory? 背：C-, T-, L-spine deformity ? Tenderness?

PE Cons: E2V1M4 GA: pale and comatous Right neck supraclavicular region: 3 cm open wound with active oozing, air- leak (?) HEENT: neck: supple,       pupil: 3+ / 3+  CHEST: breathing: bil. clear       heart: RHB, no murmur ABDOMEN: soft and flat         bowel sound:normoactive Pelvis: stable, no deformity EXTRIMITIES: freely, no open wound

14:04 (-1 min) On endo Fr.6, fix 18 cm

Initial order(14:15, 10mins later)  Rocuronium 50mg/5ml/vial, 25  MG STAT   IV On ET tube (Fr 6, fix at 18 cm ) CBC/DC, sugar, BUN, Cr, ALT, Amylase, Na, K, U/A , ABG Emergent Prepare PRBC 6U , BT PRBC 2 U IV WITH  2 line WITH 16#IC USE with N/S 1500cc challenge on EKG, BP monitor and pulse oximeter   On NG with decpmpression , Foley On neck collar C-spine lateral view, CXR, Pelvis AP view, Both FAST, wound culture

Do you agree? On 完endo才知道病患10歲，體重仍未知 Broselow tape? 此時 Broselow tape 還在另一間小兒科急救室，On 完 endo 才available 急輸O 型血?

About Further detail problems Intubation or not? yes RSI or not? yes Medication ? dose? 患者年紀10y6m 體重29kg (AD note) Size of Trachea tube10/4 +4=6 Depth 6x3=18, or 10/2 +12=17 Fluid challenge? Amount600cc st ??

FAST No fluid collection was noted in the abdomen and pericardial space Massive pleural effusion was noted over left chest

Next step?

On chest tube? Tube size? Consult CVS for surgery ? Chest CT? for definite the location of lesion? Brain CT? for coma status?

Ped. ATLS (5) Pneumothorax May not hear decreased BS b/c of easily transmitted sounds from other side See broselow for tube sizes Occult pneumos require chest tubes Signs of tension pneumothorax are often subltle: can’t see tracheal deviation b/c of short neck, may still have bilateral breath sounds heard, hypotension late

Ped. ATLS (6) Hemothorax Indication for OR thoracotomy initial drainage > 20ml/kg(>1500ml)or Ongoing drainage > 5 ml/kg/hr or continued air leak

Ped. ATLS (7) Emergency Room Thoracotomy Indications the same as adults Rarely needed but should be done if indicated Indicated in penetrating trauma only (NOT blunt) Penetrating trauma + loss of vitals at scene Penetrating trauma + loss of vital on transport Penetrating trauma + loss of vitals in ED note:NOT indicated if NO vital signs at the scene

UpToDate

14:21 (16 mins) 第一次量到血壓 BT ：35.8’C HR ：131 RR ：20 BP ：120/70 Sat ：100

14:27, 22mins later Consult CVS (第一時間看到有明顯穿刺傷口，已call CVS) 其實CVS在做完FAST，就已抵達現場 急發O型血 4 UNITS(先輸2UNITS).          

Consult sheet 電腦未回覆 紙本病歷亦無consult 單

14:39, 34min later

14:39, 34min later

14:39, 34min later

14:45 (40 mins later) 14:51 (46 mins later) 量不到血壓 On chest tube , and record amount (由外科醫師執行) On 完chest tube 後 34.5/166/20 128/56 14:51 (46 mins later)

Lab on 7/26 in the ER WBC 6200 BUN 6 mg/dl Hb. 7.8 Cr. 0.91 mg/dl PLT 198 sugar 226 mg/dl Neu. seg 29% Ca 7.5 IU/L Lym. 64% ALT 9 IU/L amylase 40

Lab on 7/26 in the ER Na 145 meq/L PH 6.696 K 2.92 meq/L PCO2 110.2 PO2 42.0 HCO3 13.2 Sat 42.9%

15:15 (70 mins later) 輸血完畢，量不到血壓 Chest tube 持續流出flash blood 目測約500CC 以上 外科醫師口頭建議CT ，確定問題後再OP

15:22 (77 mins later) 34.5/148/20 BP:量不到 主任要求外科，DC chest CT，送OR 離開急診，for OP

如果這個case 發生在台北……

1.病患進入時間:2010/07/26 15:30:00 2.醫囑麻醉開始:2010/07/26 15:30:00 3.手術準備開始:2010/07/26 15:39:26 4.手術開始劃刀:2010/07/26 16:20:00

？ 到院 14:04 -1 min 14:05 0 min 事發 時間 約14:00 On endo 掛號 15:22 77 min 14:27 22 min 14:51 46 min Chest tube 離開急診for OP Consult

OP note (1) 手術說明: LIGATION OF LEFT SUBCLAVIAN ARTERY OP Finding:  massive left hemothroax with shock at ER, partial response to blood and fluid resuscitation. left 4th rib anteriolateral thoracotomy and bleeding vessels from thoracic inlet near first rib/clavicle; disruption of pariental plerua. R/O disruption of left subclavian artery. ligation of both ends with endoclips for damage control owing to blood loss about 3400 cc. Better hemodynamic after hemostasis.

OP note (2) 手術說明: MEDIASTINOTOMY  EXPLORATION OR DRAINAGE, CERVICAL APPROACH OP Finding:    dirty right neck wound with active oozing from deep layers of avulsive rap muscles -primary closure + 6# penrose drain flexible 5mm endoscopic exploration of whole esophagus  -- no detectable lesion of esophageal mucosa    

Admission course (1) After operation, he was admitted to SICU for post-op care and treatment. extubation on 7/27 morning (Day 2), clear cons, obey and could talking and transfered to ordinary for post op care.

Admission course (2) The postoperative recovery was smooth. The left radial artery showed no pulsation, but brachial artery pulsation could be detected by doppler, the skin was warm and pink, the motor function was well. Chest tube and right neck penrose drain were removed on 8/2 (Day 8). Under the stable condition, he was discharge on 8/6 (Day 12).

Another case 2010/04/20 Dr 李怡農 reported

2010/2/13 15:10 病患因喝酒後開小貨車撞電線桿, 右下肢創傷由119送入 蘇XX Vital sign： 2931296 49y/o 男性 Triage 1 Vital sign： TPR：33.3/140/28 BP:42/26mmHg E4V4M6 病患因喝酒後開小貨車撞電線桿, 右下肢創傷由119送入

Initial Order (15min later) On O2 mask 6L/min CBC/DC, PT/APTT, BUN/Cr, Na/K/Ca/Cl/P, Amylase/Lipase, AS/ALT, Alcohol, TropI, Myoglobin, sugar, ABG CXR Toxoid 0.5PC IM STAT Moxifloxacin 1PC IVF STAT On large bore, L-R challenge 1000ml FAST echo: negative 緊急備血 PRBC 6U (15:40開始, 30min) TPR: 34.1/120/31 BP: 73/41mmHg

2010/2/13 15:48 (38min) 病患上肢僵硬眼神上吊約10秒鍾後失禁.解黃色稀便後無心跳 (護理紀錄) CPR On endo, 7.5# fix 22cm On bilateral chest tube, 32# (R: 500ml initial, L: minimal) 16:03 TPR: 35/115/14 BP: 92/65mmHg Consult CVS

2010/2/13 16:19 (1h9m) CVS consultation: 1. keep vital sign, evaluate other major organ damage 2. Do CT C(+-) for chest trauma and major great vessels evaluation 3. record CT amount per hour, if > 300cc/hr *4 hrs , we will arrange operation RT CT : 800cc stat dark red blood LT CT : few blood

ATLS Hemothorax Indication for OR thoracotomy PED initial drainage > 20ml/kg(>1500ml)or Ongoing drainage > 5 ml/kg/hr or continued air leak Indication for OR thoracotomy ADULT initial drainage >1500ml or Ongoing drainage > 200 ml/hr for 2~4 hr But base on the pt’s status

Lab Hb: 18.1 HCT: 50.4 Sugar:217 MCV: 106.8 BUN/Cr: 14.7/1.43 RDW: 12.8 PLT:123k WBC: 6500 Seg:44% Lym:53% PT/APTT: 12.6/30.2 INR: 1.1 Sugar:217 BUN/Cr: 14.7/1.43 Na/K/Cl: 140/2.8/96 Ca/P: 8.8/8.4 AST/ALT: 941/311 Amylase: 173 Lipase: 107 Alcohol: 141 CKMB: 25.8 Trop I: 2.047 Myoglobin: 1289

2010/02/13 16:32 (1h22m) Now conscious clear Well response Left side Chest tube: persistent air leakage Arrange whole body CT Blood trasnsfusion PRBC & FFP 各6U Consult Ortho 16:55, RPBC 6U & FFP 6U 開始 (1h45m) 心跳116次/分 呼吸14次/分 血壓90/40mmHg

2010/02/13 17:14 (2h4m) Conscious clear, to CT room (TPR: 35/116/20 BP: 92/48mmHg) But after contrast injection -->Loss of conscious Begin CPCR after returning to rescucitation room Chest tube amount: 1400ml fresh blood Expire at 17:55 (2h45m)

報案 14:28 0min 到院 38min 2nd CPR 1hr 22min 2hr 10min 2hr 45min 15:48 1h20m 1st CPR 38min 16:32 2h04m 會診 開立CT 17:20 2h52m 2nd CPR 17:55 3h27m Expire 1hr 22min 2hr 10min 2hr 45min

UpToDate

如果急救室有個門，打開就是CT room…

Take home message 小兒ATLS Aggressive !! 各種procedure 器械 size的選擇 RSI時，藥物與劑量的決定 Aggressive !! 同時亦應考慮氣胸、血胸、 肺挫傷、大血管損傷、心包填塞、心臟挫傷的可能性。 Hemodynamic unstable 時，先進OR ，avoid delayed by CT