Case 년 7 월 7 일 응급의학과 R3 김현종

권 0 웅 M/65  Chief Complaint Epistaxis  Duration 내원 3 시간 전

권 0 웅 M/65  PHx HTN / DM / Tbc / Hepatitis (+/-/-/-) 2002 년 nasopharyngeal ca. 진단  상계 백병원 진단.  CTx 4 cycle 2003 년 John’s Hopkins  CTx 2 cycle 2004 년 RTx 본원  Mass excision via infra-temporal fossa approach ~6.14  Admission d/t nasal bleeding

Present illness  상기 65 세 남환은 2002 년 Nasopharyngeal ca 진단 후, 본원에서 치료 중인 분으로, 내 원 3 시간 전 집에서 주무 시다가 2~3 컵 이상 의 Nasal bleeding 있어 본원 응급실로 내원 함

Review Of System  Cough / Sputum / Dyspnea (-/-/+)  Nasal obstruction / Post nasal drip (-/+)  Headache / Dizziness (+-/+)  Nausea / Vomiting (+/+)

Physical Examination  G/A Acute ill-looking appearance Alert mental status  V/S BP 86/58 mmHgPR 51 bpm BT 36.9 ℃ RR 25 rpm  HEENT Pale conjunctiva Not icteric sclera  Chest Clear breathing without rale

Physical Examination  Nasal cavity Anterior nasal oozing No active bleeding Posterior nasal drip

Impression  Post operative nasal bleeding S/p mass excision via infra-temporal fossa approach

Lab  WBC/Hb/Hct/Plt 8200/uL 7.9 g/dL 22.9% 323k/uL  PT/INR/aPTT 12.6 sec / 1.03 / 31.7sec  ABGA pH/ pCO2 / pO2 / HCO3- / BE / SaO / 25.9 / / 45.7 / 14.4 / 95.1%  BUN/Cr 21.2/1.0 mg/dL  Na/K/Cl/tCO2133/4.6/98/26 mmol/L  Glu 119 mg/dL  AST/ALT 21/32 IU/L

Progress (1)  Fluid resuscitation Initial vital sign  BP 86/58 mmHgPR 51 bpm Follow up vital sign Follow up vital sign  BP 110/72 mmHg PR 56 bpm 내원 4 시간 후 F/U CBC  WBC/Hb/Hct/Plt 8200/uL 7.4 g/dL 22.4% 323k/uL Transfusion

Progress (2)  ENT consult No active bleeding focus inside both nasal cavity Nasopharynx  Blood clot  No active bleeding status  Nasal dresssing Staff notify

Progress (3)  내원 12 시간 후 Active bleeding Irritable mental status BP 80/40mmHg PR : 90 bpm SaO2: 85 % 로 저하됨  Fluid resuscitation

Progress (4)  Intubation try Midazolam 5mg, Succinylcholine : 75mg 7.5mm tube  Intubation fail Active bleeding Difficult airway d/t known nasopharyngeal cancer

Progress (5)  2 nd intubation try SaO2 : 70% 대로 저하됨 BP :  Uncheckable on monitor  Palpable femoral pulse Pulse rate  45 bpm

Progress (6)  Surgical airway Emergent crico-thyrotomy Quick-trach set 이용  Atropine 0.5mg IV 투여  SaO 2 : 80% 이상 확보됨 Oral cavity 로 air leak Active bleeding 지속됨

Progress (7)  3 rd intubation SaO 2 : 95% BP 90/50mmHg PR: 75bpm  F/U lab WBC/Hb/Hct/Plt 13900/uL 5.6 g/dL 16.3% 224k/uL

Progress (7)  Emergency angiography and embolism

Progress (8)  #HOD 20  ENT admission  Conservative manage  RTx  금일 퇴원 예정