Case presentation 2006.07.07 Department of Emergency Medicine, Severance Hospital, Yonsei University College of Medicine R2 최양환

Patient Information 17세 남자 Chief Complaint : 교통사고 이후 의식이 떨어짐 T: 40분전 V: 오토바이 운전하고 가다 중앙선을 넘어 마주 오던 승용차와 부딪힘(친구진술)

Primary Survey and Resuscitation Airway with Cervical spine protection No sign of airway obstruction : No foreign body & not palpable mandible, tracheal and laryngeal Fx. Protecting the cervical spine (by stiff neck collar) Breathing : Ventilation and Oxygenation Symmetric chest expansion (inspection, percussion, auscultation) Not palpable bony fracture on anterior chest wall

Primary Survey and Resuscitation Circulation with Hemorrhage Control V/S BP 70/50 mmHg, PR 84 회/min RR 18 회/min BT 36.4 ℃ Femoral/radial pulsation ( + / + ) No  active bleeding site

Primary Survey and Resuscitation Disability : Brief Neurologic Examination AVPU method : responds to Vocal stimuli Pupil size & reaction : 4/4 mm, isocoric light reflex GCS Score : 15 (E4, M6, V5) Exposure/Environmental Completely undress the patient Prevent hypothermia

Lateral crosstable cervical spine x-ray

AP chest x-ray ncreased hazziness and consolidation in both hilar areas. Suggestive of the pulm. edema or pneumonic infiltration.

AP pelvis x-ray

FAST Fluid collection on Morison pouch, splenorenal recess and rectovesicular space No pericardial fluid collection

Diagnostic impression R/O Internal abd. Organ Inj & Hemoperitonium R/O Pneumohemothorax Lt. R/O Fx. Maxillary wall

Secondary Survey and Management AMPLE History and Mechanism of Injury Allergies: - Medications currently used: - Past illnesses: - Last meal: 1시간 전 Event/Environment related to the injury 오토바이 타고 가다 균형을 못 잡아 아스팔트 바닦에 왼쪽으로 넘어지고 반대편 차선에서 오던 승용차에 부딪힘

Secondary Survey and Management Head and Maxillofacial Bruise on bilateral periorbital area Tenderness on both cheek

Secondary Survey and Management Cervical spine and Neck No midline tenderness on posterior neck No subcutaneous emphysema on neck No tracheal deviation Chest Coarse breath sound on Lt. whole lung field No tenderness or bruise on anterior chest wall

Secondary Survey and Management Abdomen Soft and flat Mild tenderness on upper abd. Increased bowel sound

Secondary Survey and Management Perineum/Rectum No perineal lac. & hematoma Musculoskeletal Swelling and tenderness on left thigh

Secondary Survey and Management Neurologic Mental: drawsy Motor/ sensory on all extremities: intact

Adjuncts to the Secondary Survey CT of the head

Adjuncts to the Secondary Survey CT of the chest

Adjuncts to the Secondary Survey CT of the abdomen

Adjuncts to the Secondary Survey Contrast urography

Adjuncts to the Secondary Survey Extremity x-ray

Final diagnosis Kidney rupture, bilateral Spleen rupture Liver laceration Pneumohemothorax Lt. Lung contusion SAH, traumatic Fx. Skull basal, frontal Fx. Maxillary wall, bilateral Fx. Compression L5 Fx. transverse process L3,L4 Fx. Femur shaft, Lt.

Laboratory Result Hemoglobin 5U Transfusion p RBC 12pack 12.7->8>9.5

Laboratory Result AST/ALT 213/228 -> 133/125 IU/L

Progress 20:40 내원 20:44 (내원 4 분) BP 70/50mmHg이어 fluid resuscitation 시행 20:40 내원 20:44 (내원 4 분) BP 70/50mmHg이어 fluid resuscitation 시행 21:15 (내원 35 분) FAST에서 fluid collection있어 응급수술 위해 GS 협진 의뢰 21:40 (내원 60 분) BP 110/55mmHg으로 올라 CT 시행

Progress 22:10 (내원 1시간 30 분) CT에서 bilateral kidney and spleen rupture with hemoperitoneum 있어 응급수술 위해 비뇨기과 협진 추가 의뢰 22:20 (내원 1시간 40 분) Stuporous mental state로 endotracheal intubation 시행 23:40 (내원 3시간) Cystography 시행

Progress 23:45 (내원 3시간 5분) 응급 콩팥절제술 위해 수술 준비

Progress 00:33 (내원 3시간 57 분) 00:40 (내원 4시간 ) 02:00 (내원 5시간 20 분) 응급수술위해 수술방으로 환자 이동 00:40 (내원 4시간 ) 수술방 도착 후 pulse check 안되어 심폐소생술 시작 02:00 (내원 5시간 20 분) ROSC없어 expire선언