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1、Casepresentation96.09.04Intern胡學錦胡學錦Personalprofilen nName : 吳O民 n nGender : malen nAge : 46 years oldn nChart number : 16762291n nArrival date at ED : 96/08/20n nTime : 04:15 amInjurymechanismn nSuffered from a traffic accident with drunken state this morning (04:00am) Suspect drunken drivingn n現場生
2、命現象: drowsy and irritable (E3V3M4)n nCC: Alcoholism with Traffic accident Pre-hospitalevaluationandmanagementn nSent to KMUH ER by 119n nHead :ILOC(?), dizziness(?), headache(?), nausea/vomiting(?), amnesia(?), vertigo(?)laceration wound over rt upper eyelid and earlobe n nNeck: pain, stiff, sorenes
3、s(?)n nChest: pain, dyspnea(?)n nAbdomen: pain, discomfort(?)n nLimbs and skin : abrasion wound over bil. kneeAMPLEhistoryn nAllergies: unknownn nMedication: unknownn nPast illness:n nDM:(?) n nHTN:(?)n nOther systemic diseases(?) n nOperation history(?)n nLast Meal : (?)Initialevaluation(KMUH)A (ai
4、rway) / B (breathing):Collar fixation: (+)Airway: speech: (?) respiration: smoothairway obstruction sign (-) foreign body in the mouth (-) Trachea Breathing sound: clearl lC (circulation):l lRate: brachial a. , carotid a., femoral a. , dorsalis pedis a. l lCuff BP : 105/45 mmHgl lSkin condition: app
5、earance, temperature, humidityD (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. kneeSecondaryevaluation(KMUHER)n nChest X-ray AP & latera
6、l view n nCervical spine X-ray AP & lateral viewn nPelvis X-ray APn nBrain CT without contrast (due to drowsy consciousness and irritable state, brain CT was hold for safety concern)Labdata(96/08/20)Labdata(96/08/20)Chestx-rayCervicalspineX-rayPelvisX-rayPlann nClose observation with plaining brain
7、CT studyAt16:05n nConsciousness: coma GCS: E1V1M1 Pupil size: R/L:3.5/2.0 with negative light reflex BP: 150/78 mmHg PR:95/bpm. n nHe was sent for emeregnt brain CTn nEmergent endotracheal intubation after Citosol sedation with paralytics (Genso)Tentativediagnosisn nTraumatic ICH and SDH with mass e
8、ffect and midline shiftn nAlcoholism additionn nr/o C- spine injuryn nLeft ear lobe laceration (1cm)n nFacial laceration (2 cm) n nAbrasion wound over bilateral kneesn nUnder the impression of traumatic ICH and SDH with mass effect and midline shift, N/S was consult and he was sent to OR for emergen
9、t right craniectomy, SDH & ICH removal and ICH monitor insertion. n nThen, he was admitted to 7ENI-31 for further therapy.PostOperationn n08/21, GCS:E1 VE M2ICP was controled during 1217mmHg, and glycerol was used.n n Fever up to 39, Sputum (+) were noted. Antibiotics: Cefazolin 1g iv q8h day 2n n G
10、entamicinn nDuring 08/2208/24, spiking fever up to 40 was noted. n n08/25: The sputum culture collected on 8/22 showed Pseudomonas aeruginosa, and antibiotics shifted to Tazocin 2 vial q8h. n nDuring 08/2608/28, persisted mild fever up to 39 was noted. Follow up brain CT on 8/28: (1) Rt contusion he
11、morrhage with resolution and n n perifocal edema (2) previous left EDH had no enlargementn nRemove ICP monitor on 08/28n n08/29: fever subsided, remove endotracheal tuben n08/30: Transfer to NS wardn nQ:無法出ICU之併發症?Q:留觀待醒過程能否易留觀待醒過程能否易delaydiagnosis?Q:酒後躁動患者能否酒後躁動患者能否sedation後去做後去做brainCT?Approachton
12、euroimaginginchildren2007UpToDateApproachtoneuroimaginginchildren2007UpToDaten nSedationSedationisrarelyrequiredforCTSedationSedationisrarelyrequiredforCTexaminationsinchildrenbecausemostCTexaminationsinchildrenbecausemostCTexaminationstakeonlysecondsorminutesexaminationstakeonlysecondsorminutestope
13、rform,particularlywhenultrafasttoperform,particularlywhenultrafasthelical/spiralormultidetector/multislicehelical/spiralormultidetector/multislicetechnologyisused.technologyisused.n nHigh-resolutionstudiesthatrequireHigh-resolutionstudiesthatrequireimmobilizationtoavoidmotionartifact(eg,immobilizati
14、ontoavoidmotionartifact(eg,temporalboneexamination)arethetemporalboneexamination)aretheexception.Anewbornoryounginfantoftenexception.Anewbornoryounginfantoftencanbeexaminedduringsleep(eg,afteracanbeexaminedduringsleep(eg,afterafeedingorattheusualnap-time).feedingorattheusualnap-time).Hepatictrauma:C
15、TfindingsandconsiderationsbasedHepatictrauma:CTfindingsandconsiderationsbasedonourexperienceinemergencydiagnosticimagingonourexperienceinemergencydiagnosticimagingEuropeanJournalofRadiologyVol:50Issue:1,April,EuropeanJournalofRadiologyVol:50Issue:1,April,2004p:59-662004p:59-66n nIn the case of non c
16、ooperative patients, presenting with neurological signs, sedation may be required and also assisted ventilation eventually, with continuous monitoring of cardiac and respiratory parameters. UseofIntravenousMethohexitalasaSedativeinPediatricUseofIntravenousMethohexitalasaSedativeinPediatricEmergencyD
17、epartmentsHananSedik,MDEmergencyDepartmentsHananSedik,MDArchPediatrAdolescMed.2001;155:665-668ArchPediatrAdolescMed.2001;155:665-668n nMethohexital has been used in adult emergency Methohexital has been used in adult emergency departments and has been found to produce rapid and departments and has b
18、een found to produce rapid and brief sedation, especially for orthopedic procedures. brief sedation, especially for orthopedic procedures. n nLerman et al studied 76 adult patients in a prospective Lerman et al studied 76 adult patients in a prospective observational study where IV methohexital had
19、been observational study where IV methohexital had been used for a variety of procedures, and concluded that it used for a variety of procedures, and concluded that it caused clinically insignificant changes in hemodynamics caused clinically insignificant changes in hemodynamics and oxygenation. Alt
20、hough respiratory depression did and oxygenation. Although respiratory depression did occur, if significant it was brief and easily managed. occur, if significant it was brief and easily managed. n nZink et al reported a consecutive case series of 102 Zink et al reported a consecutive case series of
21、 102 patients (including 10 patients younger than 10 years) patients (including 10 patients younger than 10 years) who received IV methohexital for various procedures. who received IV methohexital for various procedures. The authors concluded that methohexital is safe and The authors concluded that
22、methohexital is safe and effective in selected emergency department patients. effective in selected emergency department patients. Current conditionn nAdmission to 7B 27-1Admission to 7B 27-1n nGCS:E2 V2 M3GCS:E2 V2 M3n nBP: 109/78 mmHgBP: 109/78 mmHgn nPupil: R 2.5mm L 2.5mm, bilateral prompt refle
23、x Pupil: R 2.5mm L 2.5mm, bilateral prompt reflex n n MP R L MP R L n n upper limb 2 1 upper limb 2 1n n lower limb 2 2 lower limb 2 2 n nPlan :Plan :n n1. keep Saxizon 100mg iv q8h second day due 1. keep Saxizon 100mg iv q8h second day due to bilateral bronchus wheezingto bilateral bronchus wheezin
24、gn n2. Antibiotics: Tazocin 2 vial iv q8h day 92. Antibiotics: Tazocin 2 vial iv q8h day 9n n3. Consult rehabilitation department3. Consult rehabilitation departmentThanks for attentionLermanB,YoshidaD,LevittMA.AprospectiveLermanB,YoshidaD,LevittMA.Aprospectiveevaluationofthesafetyandefficacyofmetho
25、hexitalinevaluationofthesafetyandefficacyofmethohexitalintheemergencydepartment.AmJEmergMed.theemergencydepartment.AmJEmergMed.1996;14:351-354.1996;14:351-354.n nMTX 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.
