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: 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 O 2 2L/min  On SpO 2 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 (1442) 檢 體 :Blood 項 目 : NA K AST ALT 日期 ( 時間 ) m mol/L m mol/L IU/L IU/L (1442) 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 (1442) 檢 體 :Blood 項 目 : RDW-CV RDW-SD 日期 ( 時間 ) % fl (1442)

CXR 96/08/30

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

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 )

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~