ER case conference

ER case conference 96/09/11(二) 陳昭文醫師指導 Intern 林懿慧

Patient’s Profile • Name: 楊O宏 • Gender: male • Age: 25 years old • Chart number: 23878362 • Arrival time: 2007/08/30,14:29 • Transferred from 高新 hospital

Arrival status • Consciousness : Clear, E4V5M6 • Vital signs : • Respiratory rate: 14 cpm • Blood pressure: 118 / 73 mmHg • Pulse: 86 bpm • Temperature: 36.2 ℃ • Foley in situ

Primary Survey • Airway: patent • Breathing: • Nasal O2 2L/min • On SpO2 monitor, regular breathing RR 14/min, SpO2 94% • Bilateral clear on auscultation • Circulation: • On EKG monitor, HR 86/min, BP 118/73 mmHg • Skin/mucosa: red, humid,warm • Set IVF with N/S 500 ml • No external hemorrhage • Disability • E4V5M6 • Pupil size:？

Chief Complaint • Acute lower limbs weakness and loss of sensation after back crushed by heavy weight (100多公斤的塑膠板) since around 12 o’clock of 96/08/30

Present Illness • A 25-year-old male who is a victim of trauma during working suffered from acute lower limbs weakness and loss of sensation after back crushed by heavy weight at 12:00 of 96/08/30. • He brought to 高新 H for help and the airway, breathing and circulation systems were normal. consciousness was clear. • The lower limbs muscle power were zero with loss of sensation. There was no specific wounds after exposure. • The X-ray in 高新 H showed L1 dislocated fracture. He was transferred to our ER for help.

Past History • Allergies: denied • Medications: denied • Past illness: • Systemic disease: denied • OP history: denied • Last meal:？

Family History

Physical examination • Consciousness: clear, E4V5M6 • Vital signs: BP: 118/73mmHg, RR: 14/min, HR: 86/min, BT: 36.2C • Head • Conjunctiva: no pale • Sclera: no icteric • Neck: supple, no tenderness or soreness • Chest: symmetric expansion, no tenderness • Breathing sound: bilateral clear • Heart sound: no murmur, RHB • Abdomen: soft, flat • Bowel sound: normoactive • Percussion: tympanic • Palpation: no tenderness • Lower legs: no pitting edema • Loss of sensation and immobility below L1 dermatome • Anal tone: loosen

Management at ER • Check laboratory data • X-ray (abdominal AP/Lat) • Abdominal CT(C+/-) + L-spine CT • 12 leads EKG • 長背板 use • Fluid supply with N/S 500 ml ivd

Lab Data 緊急生化檢驗 • 檢體 :Blood 項目 : PT p PT c PT(INR) PTT P PTT C GLU BUN CREA 日期(時間) second second R second second mg/dl mg/dl mg/dl 960830(1442) 10.9 11.1 1.10 23.6 28.2 147 10.8 1.1 • 檢體 :Blood 項目 : NA K AST ALT 日期(時間) m mol/L m mol/L IU/L IU/L 960830(1442) 141 3.7 42 29 一般血液檢驗 • 檢體 :Blood 項目 : WBC RBC HGB HCT MCV MCH MCHC PLT 日期(時間) x1000/ul x10^6/ul g/dl % fl Pg g/dl x1000/ul 960830(1442) 14.48 4.99 13.1 40.8 81.8 26.3 32.1 231 • 檢體 :Blood 項目 : RDW-CV RDW-SD 日期(時間) % fl 960830(1442) 13.7 40.4

CXR 96/08/30

T12 T12 L1 L1 Abd AP/Lat 96/08/30

Abd CT 96/08/30

Abd CT 96/08/30 • Chance fracture of the L1 with severe posterior displacement and hemoretroperitoneum. Suspect transection of the spinal cord. • Suspect hematoma in the mesentary without active contrast extravasation. • Fractures at left pedicle of the T12, bilateral transverse processes of L3. • Disc bulging of the L4-5 and L5-S1 with mild compression of the spinal canal. Wei-Shiuan Chung / Yu - Ting Kuo , M.D. 郭禹廷醫師(放診專醫字第000437)

Initial Diagnosis • L1 transection with dislocated fracture • Retroperitoneal hematoma

Management at ER • Add megadose steroid：Solumedrol 17 vials +N/S 500 ml keep 30 c.c/hr • Observe the progression of neurological signs • Observe the change of vital signs：watch out possibility of spinal shock • Pain control with Laston 1 Amp iv • Consult NS and arrange operation • Admit to SICU (NS)

Operation on 96/09/04 • T11,T12,l1,L2 laminectomy and L1 corpectomy+duroplasty under microscope +T10,11,12,L2,3 TPSx10

Post-Operation Plan • Rinderon 1amp q6h iv • Gaster 1 amp q12h • Cefazolin 1g q8h +gentamycin 1vial q12h • Chest care and sputum suction • Consult Reh and start Reh program

Spinal Cord Injury (SCI): Damage Control and Treatment

Today, there's still no way to reverse damage to the spinal cord. • Spinal cord injury treatment focuses on prevent further injury and enable people with a spinal cord injury to return to an active and productive life within the limits of their disability. • Improved emergency care and aggressive treatment and rehabilitation can minimize damage to the nervous system and even restore limited abilities.

Emergency actions • Medications. • Methylprednisolone which is a treatment option for acute spinal cord injury should begin as soon as possible after the injury. • Cause some recovery in people with a spinal cord injury if given within 8 hours of injury. • Reduce damage to nerve cells and decrease inflammation near the site of injury. • Immobilization. • Stabilize the spine and bring the spine into proper alignment during healing.

Ongoing care • Surgery. • Surgery is necessary to remove objects that compress the spine. • Spinal instrumentation and fusion can be used to provide permanent stability to prevent future pain or deformity. • Controversy exists regarding the best time to perform surgery. Soon or wait for several days？ • Rehabilitation. • Extensive physical therapy, occupational therapy, and other rehabilitation interventions • Social and emotional support. • Anti-spasticity medications

Thanks for your listening~

ER case conference

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