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96.09.0496.09.04 Intern Intern 胡學錦胡學錦

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Name : Name : 吳吳 OO 民民 Gender : maleGender : male Age : 46 years oldAge : 46 years old Chart number : 16762291Chart number : 16762291 Arrival date at ED : 96/08/20Arrival date at ED : 96/08/20 Time : 04:15 amTime : 04:15 am

Injury mechanismInjury mechanism

Suffered from a traffic accident with drunkSuffered from a traffic accident with drunken state this morning (04:00am) Suspect den state this morning (04:00am) Suspect drunken drivingrunken driving

現場生命現象現場生命現象 : drowsy and irritable: drowsy and irritable (E3V3(E3V3M4)M4)

CC: Alcoholism with Traffic accident CC: Alcoholism with Traffic accident

Pre-hospital evaluation and Pre-hospital evaluation and managementmanagement

Sent to KMUH ER by 119Sent to KMUH ER by 119 Head :ILOC(?), dizziness(?), headache(?), Head :ILOC(?), dizziness(?), headache(?),

nausea/vomiting(?), amnesia(?), vertigo(?)nausea/vomiting(?), amnesia(?), vertigo(?)laceration wound over r’t upper eyelid and laceration wound over r’t upper eyelid and earlobe earlobe

Neck: pain, stiff, soreness…(?)Neck: pain, stiff, soreness…(?) Chest: pain, dyspnea…(?)Chest: pain, dyspnea…(?) Abdomen: pain, discomfort…(?)Abdomen: pain, discomfort…(?) Limbs and skin : Limbs and skin :

abrasion wound over bil. kneeabrasion wound over bil. knee

AMPLE historyAMPLE history

Allergies: unknownAllergies: unknown Medication: unknownMedication: unknown Past illness:Past illness:

DM:(?) DM:(?) HTN:(?)HTN:(?) Other systemic diseases(?) Other systemic diseases(?) Operation history(?)Operation history(?)

Last Meal : (?)Last Meal : (?)

Initial evaluation Initial evaluation (KMUH)(KMUH)

A (airway) / B (breathing):A (airway) / B (breathing): Collar fixation: (+)Collar fixation: (+) Airway: speech: (?)Airway: speech: (?)

respiration: smooth respiration: smooth airway obstruction sign (-)airway obstruction sign (-) foreign body in the mouth (-) foreign body in the mouth (-) Trachea Trachea Breathing sound: clearBreathing sound: clear

C (circulation):C (circulation): Rate: brachial a. , carotid a., Rate: brachial a. , carotid a.,

femoral a. , dorsalis pedis a. femoral a. , dorsalis pedis a. Cuff BP : 105/45 mmHgCuff BP : 105/45 mmHg Skin condition: Skin condition:

appearance, temperature, humidity appearance, temperature, humidity

D (disable):D (disable): GCS: GCS: E2V2M5E2V2M5 Pupil response: Pupil response:

od: 2 mm od: 2 mm os: 2 mm os: 2 mm

E ( exposure ) : E ( exposure ) : abrasion wound over nose and bil. maxillary areabrasion wound over nose and bil. maxillary are

a, a, laceration wound over r’t. upper eyelid(2 cm) anlaceration wound over r’t. upper eyelid(2 cm) an

d earlobe(1 cm)d earlobe(1 cm) abrasion wound over bil. kneeabrasion wound over bil. knee

Secondary evaluation Secondary evaluation (KMUH ER)(KMUH ER)

Chest X-ray AP & lateral view Chest X-ray AP & lateral view Cervical spine X-ray AP & lateral viewCervical spine X-ray AP & lateral view Pelvis X-ray APPelvis X-ray AP Brain CT without contrast Brain CT without contrast ((due to due to

drowsy consciousness and irritable drowsy consciousness and irritable state, brain CT was hold for safety state, brain CT was hold for safety concernconcern))

Lab data (96/08/20)Lab data (96/08/20)

Lab data (96/08/20)Lab data (96/08/20)

Chest x-rayChest x-ray

Cervical spine X-rayCervical spine X-ray

Pelvis X-rayPelvis X-ray

PlanPlan

Close observation with plaining brain CT stClose observation with plaining brain CT studyudy

At 16:05At 16:05 Consciousness: Consciousness: coma coma

GCS:GCS: E1V1M1 E1V1M1 Pupil size: Pupil size: R/L:3.5/2.0R/L:3.5/2.0 with negative light r with negative light reflex eflex BP: 150/78 mmHg PR:95/bpm. BP: 150/78 mmHg PR:95/bpm.

He was sent for emeregnt brain CTHe was sent for emeregnt brain CT Emergent endotracheal intubation after CitEmergent endotracheal intubation after Cit

osol sedation osol sedation withwith paralytics (Genso) paralytics (Genso)

Tentative diagnosisTentative diagnosis

Traumatic ICH and SDH with mass effect Traumatic ICH and SDH with mass effect and midline shiftand midline shift

Alcoholism additionAlcoholism addition r/o C- spine injuryr/o C- spine injury Left ear lobe laceration (1cm)Left ear lobe laceration (1cm) Facial laceration (2 cm) Facial laceration (2 cm) Abrasion wound over bilateral kneesAbrasion wound over bilateral knees

Under the impression of traumaticUnder the impression of traumatic ICH ICH andand SDH with mass effect SDH with mass effect and and midline shiftmidline shift, N/, N/S was consult and he was sent to OR for eS was consult and he was sent to OR for emergent mergent right craniectomyright craniectomy,, SDH & ICH re SDH & ICH removal moval andand ICH monitor insertion ICH monitor insertion. .

Then, he was admitted to 7ENI-31 for furthThen, he was admitted to 7ENI-31 for further therapy.er therapy.

Post Operation Post Operation

08/21, GCS:E1 VE M208/21, GCS:E1 VE M2ICP was controled during 12~17mmHg, anICP was controled during 12~17mmHg, and glycerol was used.d glycerol was used.

Fever up to 39Fever up to 39℃, ℃, Sputum (+) were noted. Sputum (+) were noted. Antibiotics: Cefazolin 1g iv q8h day 2Antibiotics: Cefazolin 1g iv q8h day 2

GentamicinGentamicin

During 08/22~08/24, During 08/22~08/24, spiking fever up to 40 spiking fever up to 40 ℃℃ was noted. was noted.

08/25: The sputum culture collected on 8/208/25: The sputum culture collected on 8/22 showed 2 showed Pseudomonas aeruginosaPseudomonas aeruginosa, and , and antibiotics shifted to Tazocin 2 vial q8h. antibiotics shifted to Tazocin 2 vial q8h.

During 08/26~08/28, During 08/26~08/28, persisted mild fever upersisted mild fever up to 39 p to 39 ℃℃ was noted. was noted. Follow up brain CT on 8/28: Follow up brain CT on 8/28: (1) R’t contusion hemorrhage with resolution and (1) R’t contusion hemorrhage with resolution and

perifocal edema perifocal edema (2) previous left EDH had no enlargement(2) previous left EDH had no enlargement

Remove ICP monitorRemove ICP monitor on 08/28 on 08/28

08/29: 08/29: fever subsided, fever subsided, remove endotracheal tuberemove endotracheal tube

08/30: Transfer to NS ward08/30: Transfer to NS ward

Q:Q: 無法出無法出 ICUICU 之併發症之併發症 ??

Q:Q: 留觀待醒過程是否易留觀待醒過程是否易 delay diagnosis? delay diagnosis?

Q:Q: 酒後躁動患者是否酒後躁動患者是否 sedationsedation 後去做後去做 brain brain CT?CT?

Approach to neuroimaging in children 2007 UpToDateApproach to neuroimaging in children 2007 UpToDate SedationSedation — Sedation is rarely required for CT e — Sedation is rarely required for CT e

xaminations in children because most CT examixaminations in children because most CT examinations take only seconds or minutes to perform, nations take only seconds or minutes to perform, particularly when ultrafast helical/spiral or multidparticularly when ultrafast helical/spiral or multidetector/multislice technology is used.etector/multislice technology is used.

High-resolution studies that require immobilizatioHigh-resolution studies that require immobilization n to avoid motion artifact (eg, temporal bone exato avoid motion artifact (eg, temporal bone examination)mination) are the exception. A newborn or young are the exception. A newborn or young infant often can be examined during sleep (eg, ainfant often can be examined during sleep (eg, after a feeding or at the usual nap-time).fter a feeding or at the usual nap-time).

Hepatic trauma: CT findings and considerations based Hepatic trauma: CT findings and considerations based on our experience in emergency diagnostic imagingon our experience in emergency diagnostic imaging

European Journal of RadiologyVol: 50 Issue: 1, April, 2European Journal of RadiologyVol: 50 Issue: 1, April, 2004  p: 59-66004  p: 59-66

In the case of In the case of non cooperative patientsnon cooperative patients, , presenting with presenting with neurological signsneurological signs, , sedation may be required and also sedation may be required and also assisted ventilationassisted ventilation eventually, with eventually, with continuous monitoring of cardiac and continuous monitoring of cardiac and respiratory parameters. respiratory parameters.

Use of Intravenous Methohexital as a Sedative in Pediatric EmergeUse of Intravenous Methohexital as a Sedative in Pediatric Emergency Departments ncy Departments Hanan Sedik, MDHanan Sedik, MD

Arch Pediatr Adolesc Med.Arch Pediatr Adolesc Med. 2001;155:665-668 2001;155:665-668

MethohexitalMethohexital has been used in adult emergency departm has been used in adult emergency departments and has been found to produce ents and has been found to produce rapid and brief sedarapid and brief sedationtion, especially for orthopedic procedures. , especially for orthopedic procedures.

Lerman et al studied 76 adult patients in a prospective oLerman et al studied 76 adult patients in a prospective observational study where IV methohexital had been used bservational study where IV methohexital had been used for a variety of procedures, and concluded that it caused for a variety of procedures, and concluded that it caused clinically insignificant changes in clinically insignificant changes in hemodynamics and oxyhemodynamics and oxygenationgenation. Although . Although respiratory depressionrespiratory depression did occur, if si did occur, if significant it was brief and easily managed. gnificant it was brief and easily managed.

Zink et al reported a consecutive case series of 102 patiZink et al reported a consecutive case series of 102 patients (including 10 patients younger than 10 years) who rents (including 10 patients younger than 10 years) who received IV methohexital for various procedures. The auteceived IV methohexital for various procedures. The authors concluded that hors concluded that methohexital is safe and effectivemethohexital is safe and effective in in selected emergency department patients. selected emergency department patients.

Current conditionCurrent condition Admission to 7B 27-1Admission to 7B 27-1

GCS:E2 V2 M3GCS:E2 V2 M3 BP: 109/78 mmHgBP: 109/78 mmHg Pupil: R 2.5mm L 2.5mm, bilateral prompt reflex Pupil: R 2.5mm L 2.5mm, bilateral prompt reflex MP R L MP R L upper limb 2 1upper limb 2 1 lower limb 2 2 lower limb 2 2 Plan :Plan :1. keep Saxizon 100mg iv q8h second day due to bilater1. keep Saxizon 100mg iv q8h second day due to bilater

al bronchus wheezingal bronchus wheezing2. Antibiotics: Tazocin 2 vial iv q8h day 92. Antibiotics: Tazocin 2 vial iv q8h day 93. Consult rehabilitation department3. Consult rehabilitation department

Thanks for attention~

Lerman B, Yoshida D, Levitt MA. A prospective evaluatiLerman B, Yoshida D, Levitt MA. A prospective evaluation of the safety and efficacy of methohexital in the emeon of the safety and efficacy of methohexital in the eme

rgency department. rgency department. Am J Emerg Med.Am J Emerg Med. 1996;14:351-354. 1996;14:351-354. MTX caused clinically insignificant changeMTX caused clinically insignificant change

s in s in hemodynamicshemodynamics or or oxygenationoxygenation, althou, although gh respiratory depressionrespiratory depression did occur; signifi did occur; significant respiratory depression was brief and cant respiratory depression was brief and easily managed. MTX provided rapid and easily managed. MTX provided rapid and excellent levels of sedation with little or no excellent levels of sedation with little or no patient recall or pain. patient recall or pain.