病例讨论 脑外伤病例讨论 脑外伤.doc

Patient： A 27 years old male. Chief complaint: Suffering from brain trauma for 7- hours. Present history: The patient fell down and knocked his head when he climbed to upper bed about 11:00 am. He felt dizzy and headache. He had received some treatment (not exactly knew) in spanish level I hospital about 15:30 pm. Then he suddenly could not speak, so he was sent to our hospital immediately at 17:40 pm. Emergency process: At 17:40 When the patient arrived our hospital, he was dysphoria , could not answer any question. The vital signal was normal: P 78/min; R 18 / min. Both pupil were normal(about 3.0mm), reflected to light well. So we decided to take a x-ray of skull. According to those symptoms and physical signs, we doubted internal cranium bleeding which should take CT and operate as soon as possible. So our SMO kept connection with MO-OPS in order to evacuate the patient to level 3 hospital by heli. At 17:43 In X-ray room, we found that the patient’s hyperspasmia with senseless. The rate of respiration was 26/min. The patient’s pulse was 84/min. We transfer him to emergency room. At 17:44 The patient took oxygen. Both pupil were 3.0 mm, . reflected to light well. BP 160/80 mmHg, P 62/min. 250 ml 20% mannitol was given. At 17:46 The size of left pupil was about 2.5 mm and right pupil 3.5 mm. Tracheal intubation was finished. 10mg diazepam and 40mg furosemide were injected by vein aisle. At 17:50 Hyperspasmia got worse. Catheterization was done. The second 10mg diazepam was given. At 17:55 The size of left pupil was about 2.0 mm and right pupil 3.5 mm with senseless. The third 10mg diazepam was given. At 17: 59 The patient must be to level III hospital to take CT and operation. The heli could take off due to bad weather, so we evacuated him by ambulance. The urine volume was 750 ml and the infusion volume was 300 ml in our hospital. The vital signal as follows: P 60/min; R 28 / min, BP 156/78mmHg. Two Iv fluids were build. 30mg diazepam, 200 ml 20% m