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

2. 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

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

4. 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

5. 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

6. 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

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

8. 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

9. 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

10. 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

11. 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

12. Chest PA revealed left clavicle fracture

13. 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

14. 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

15. 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 …

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

18. 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

23. 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

24. 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

25. Discussion

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

27. 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

28. 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

29. Neurologic deficit
Reference: Tintinalli Emergency medicine

30. 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

31. 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

32. 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

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