Trauma Combine Meeting PRESENTATION: ER 謝易達醫師 SUPERVISOR: ER 廖書晨醫師 DATE: 2014/05/06

2014/04/25 15:46(0hr0m) 36 year-old male Chart Number: 檢傷主訴:病患來診為119送入朋友 表示病患喝酒後跌倒現額頭處撕裂 傷 Triage vital signs: T/P/R: 35/87/18 BP: 95/62 mmHg GCS: E4V4M5

ATLS primary survey A: patent airway B: fair respiratory pattern C: bleeder forehead D: drowsy consciousness E: no other external ecchymosis or bleeder

Present Illness sent by EMT; drunken status with neck collar EMT claimed the patient had his head contuse to a parked car No other witness left forehead laceration wound ILOC: unknown Unknown past history or allergy

Physical Examination Conscious : E4V4M5~6, drunk HEENT not anemic   not icteric   **Two 6-8cm long laceration with one irregular shaped over left forehead with bony exposure(+); another over right eye brow around 6 cm; no racoon eye ; no ear bleeding  Chest  BS : clear       HS : RHB , no murmur Abdomen   soft and flat, no tenderness; bowel sound : normoactive Extremity: freely movable

2014/04/25 16:00(0hr14m) Impression: contusion of the head; open wound of the face Management: On BP monitor+ EKG monitor Ivf: Normal saline 500ml challenge and then run 80ml/hr Check: PT/APTT, CBCDC, blood ethyl alcohol, Na, K ABG Brain CT C- and facial bone C- C spine lateral view, pelvis AP Tetanus injection 缺會診紀錄

Brain CT no ICH or skull bone fracture; facial bone CT no fracture C-spine lateral view:

2014/04/25 16:50 (0hr54m) Consult Trauma team 外傷小組會診建議事項: 1.Traumatic C spine tear drop closed fracture and head contusion --closed monitor V/S and GCS at ER for 12hrs,等酒醒 --IV hydration and on Foley, NPO, on neck collar protection --no family member available but his friend at ER, explained the observation reason and risk of delay bleeding 2.Facial irregular L/W wound --consult plasty if no neurologic sign progression for wound repair before MBD 3.Thanks! The patient could obey later The plasty man came and suggested op for dirty and deep wound

Lab data item data Data WBC 13.5k/uL creatinine 1.03 mg/dL RBC 4.69 million/uL ALT 35U/L Hb 15 g/dL Na 144meq/L Hct 44.5% K 3.76 meq/L Platelet 216k/uL Alcohol 266.9 mg/dL Segment 66% VBG pH 7.343 lymphocyte 31% VBG CO2 38.8 monocyte 3% VBG H2CO3 20.6

2014/04/25 17:16() Observation order 觀察理由: 觀察症狀 Vital signs: q8H GCS: q4H Medication: Mefenamic acid 250mg qid Wound care with normal saline wet dressing q8h and prn IVF: Normal saline 1000ml run 120ml/hr On neck collar NPO except medication

2014/04/25 21:17 (5hr21m) =Pre-op order= 2014/4/26 OP site face Anesthesia: local Op procedure: primary suture of the forehead wound Keep observation at ER after operation 手術結束時間: 2014/04/25 23:34 2014/4/26 Complained of left shoulder pain CxR left clavicle fracture on 8-figure fixation and pain control

Chest PA revealed left clavicle fracture

2014/04/26 09:20(17hr24m) The patient was sent to GS ward on the service of Dr 黃 Admission diagnosis C3 fracture, teardrop, anterior Chest contusion Left clavicle fracture Facial laceration wound s/p op

Hospital Course 2014/04/26 2014/04/27~28 Complained of back soreness Four limb muscle power 5, free 2014/04/27~28 Stable vital signs No focal weakness or numbness For back pain KUB on 04/28 morning

TL spine AP and lateral view was ordered later on the same day … What did you see? Report: Calcification of right renal region Degenerative changes of lumbar and thoracic spine with spur formation TL spine AP and lateral view was ordered later on the same day …

TL spine lateral and AP view: Degenerative changes of lumbar spine with spur formation Compression fracture over T11, T12

2014/04/29 2014/04/30 Stable vital signs No decreased muscle power, no numbness 2014/04/30 CT of whole spine Burst fracture of T12 Left pleural effusion, favor chest contusion related Consult CVS  pigtail drainage of some hemothorax

Spine CT Report on 04/29 Fracture at the anterior inferior aspect of C3 vertebral body and C5~7 spinous process Compression at T11 T12 burst fracture as well as fracture of bilateral pedicles, lamina, facet and spinous process of T12 Spinal canal stenosis, instability, scoliosis and kyphosis deformity at T12 level Fracture of left T3~4, T10~12ribs and left transverseproscess of L1~2 Left pleural effusion

Hospital Course 2014/05/03 Operation for TL spine injury: Reduction of T12 burst fracture + T10 to L2 posterior fusion with smartloc pedicle screw and left posterior iliac bone graft and stinulan bone graft(5 c.c.) The patient was still hospitalized under stable vital signs at orthopedic ward now. Current diagnosis: T12 burst fracture C3 fracture and C5C6 spinous process fracture Left clavicle fracture Left lung contusion and hemothorax

Discussion

Why do we miss the TL spine injury at the early time?

Introduction of TL spine trauma Mostly T11~L2( thoracic cage relatively fixed, T11 to L2 as a transitional segment) At the end of spinal cord and transit to nerve roots of cauda equina (neurologic deficit may be complete, partial, or even no neurologic deficit) Nerve root radiculopathy and/or Cauda Equina syndrome may occur, but absence of cauda equina or neurologic sign didn’t exclude the TL spine trauma Reference: UptoDate

Patterns of TL spine fracture Type of trauma Description Stability Wedge compression fracture Axial load while flexion Unstable unless compression>50% of height or kyphosis>30’ Burst fracture Axial compression while fall or vehicle collisons Usually considered unstable Flexion distraction fracture Distraction force, men on a lap belt without chest restraint Translational fracture Translation force, may associated with fracture dislocation and neurologic deficit unstable Reference: UptoDate

Neurologic deficit Reference: Tintinalli Emergency medicine

Why do we miss the TL spine trauma at the very early time? The patient was drunk Other traumatic condition such as C spine fracture and open wound may DISTRACT the doctor

Risk factors of TL spine injury Focal pain or tenderness over the TL spine Signs of the injury(eg. Brusing hematoma) along the TL spine High force mechanism Fall from >3 meter, ejection from a vehicle, moderate-high velocity motor vehicle collisons, auto versus pedetrians, forceful direct blow Painful distracting injury with/ without neurologic deficit Presence of another spine injury particularly a known cervical fracture GCS<15 Reference: UptoDate; Eastern Association of the surgery of trauma practice guidelines

What should we do to prevent ourselves from similar pitfall? Primary ABCDE and Secondary survey!! Take precaution immobilization(long board or hard board) if spine trauma can’t be excluded Re-evaluation the drunk patient after he woke up Give radiography exam if any positive risk factors mentioned above

THANK YOU FOR YOUR ATTENTION! The End THANK YOU FOR YOUR ATTENTION!