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“come fly with me” A Case Discussion

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  1. “come fly with me”A Case Discussion Ryan Em C. Dalman MD MBA - 070070 February 17, 2010

  2. Objectives • Present a case of trauma • History and Physical Exam • Diagnostics • Differentials • Discuss it’s basic concepts of management

  3. Case Presentation Patient History

  4. General Data MDG 36-year-old Male Born on Dec 29, 1974 Roman Catholic Lives in Antipolo City Informant: Wife, 50% reliability

  5. Chief Complaint Nahulogmulasa second floor the bahay Fall

  6. History of Present Illness 1 day PTA Consult • Patient was intoxicated and fell on the 2nd floor of their house • Hit the head first on the pavement • Lost consciousness and unresponsive • No seizures, vomiting • Rushed to a nearby hospital • CT-scan: multiple cortical and subcortical contusion, subarachnoid and subdural hematoma, multiple skull fractures • Patient was deteriorating

  7. Review of Systems General: no weight loss, no change in appetite Cutaneous: no lesions, no change in color, no pruritus HEENT: no headaches no redness no aural/nasal discharge no neck masses no sore throat Cardiovascular: no easy fatigability, no fainting spells

  8. Review of Systems Respiratory: no cough, colds Gastrointestinal: no abdominal pain, no change in bowel movements Genitourinary: no pain in urination or difficulty in urinating Endocrine: no polyuria, polydypsia, no heat/cold intolerance Muskuloskeletal: no weakness, numbness on all extremities Hematopoietic: no easy bruisability, or bleeding

  9. Past Medical History No Hypertension, Diabetes, Asthma, PTB No Cancer, Allergies to food or medications No previous surgeries or hospitalizations No maintenance medications

  10. Family History Hypertension, maternal No heart disease, cancer, stroke, diabetes, asthma, or allergies

  11. Personal and Social History Married OFW at Qatar Lives with her family in a 2 story house Smoking 10 pack years Occasional alcoholic beverage drinker Denies substance abuse

  12. Case Presentation Physical Exam

  13. Physical Exam • General Survey • Intubated and unconscious • Vital Signs • Febrile at 38oC • RR 20 bpm • HR 150-160bpm • Height:168cm weight:70kg BMI:24.8

  14. Physical Exam Skin Multiple abrasions on the extremities Head soft tissue swelling of the entire head (including the face) sutured lacerations on the temporo-occipital portion of the head Eyes Swollen eyelids

  15. Physical Exam Neck with neck brace Chest adynamicprecordium no heaves, thrills, or lifts, PMI at 5th ICS MCL Distinct S1 anf S2 Tachycardic, normal rhythm no murmurs Lungs symmetrical chest expansion, no retractions with bilateral crackles

  16. Physical Exam Abdomen flat, no lesions normoactive bowel sounds tympanitic on all quadrants soft, no guarding no masses, no organomegally Extremities Semi-purposeful movement No signs of fractures or deformities Multiple abrasions noted on the arms and legs Full and equal pulses

  17. Salient Features History • 36 year old male • Fell from a 2 story building, head first • CT scan showing multiple cortical and subcortical contusion, subarachnoid and subdural hematoma, multiple skull fractures • Alcohol intoxication • Unconscious • No seizures, no vomiting Physical Exam • Soft tissue swelling of the head • sutured lacerations on the temporo-occipital area • Bilateral lung crackles • No signs of fractures (extremities)

  18. Case Discussion

  19. Primary Impression Traumatic brain injury, severe cortical and subcortical contusions Subarachnoid and subdural hematoma Multiple skull fractures Rule out pulmonary contusion

  20. Head CT

  21. Trauma Schwartz’s Principles of Surgery , 9thed Definition ….Cellular disruption caused by an exchange with environmental energy that is beyond the body’s resilience…”

  22. Trauma Schwartz’s Principles of Surgery , 9thed • Most common cause of death • 1-44 years old • 3rd most common cause of death regardless of age • Number 1 cause of years of productive life lost

  23. Trauma Merck Manual 2009 Types of Trauma • Blunt – forceful impact • Blow, kick, strike with object, fall, motor vehicle collision, blast • Penetrating – breech of the skin by an object/projectile • Knife, broken glass • Bullet, shrapnel from explosion • Other injuries • Thermal and chemical burns, toxic inhalations or ingestions, and radiation injuries

  24. Traumatic Brain Injury Merck Manual 2009 Also known as acquired brain injury, head injury Occurs when a sudden trauma damages the brain and disrupts normal brain function

  25. Traumatic Brain Injury Medscape, Emedicine • Annual statistics of TBI in the US • At least 1.4 M • 50,000 mortality • 475,000 occur among 0-14yo • 80-90k people experience the onset of a long-term disability

  26. Traumatic Brain Injury Medscape, Emedicine • Leading causes of TBI • Falls – 28% • MVA – 20% • Being struck by or against objects - 19% • Assaults - 11%

  27. Classification Medscape, Emedicine Glasgow coma scale Mild: 13-15 Moderate: 9-12 Severe: 3-8

  28. Classification Medscape, Emedicine Loss of consciousness

  29. Pathophysiology Medscape, Emedicine Primary Injury Induced by mechanical force and occurs at the moment of injury Secondary Injury Occurs hours or days after the inciting trauma

  30. Pathophysiology Medscape, Emedicine/ Merck Manual 2009 Primary Injury • Contact • Scalp injury • Skull fracture • Surface contusion • Acceleration-deceleration • Shear, tensile, compressive strains • Coup and countercoup

  31. Pathophysiology Medscape, Emedicine/ Merck Manual 2009 Primary Injury • Contusion – distinct areas of swollen brain tissue • poles and inferior aspects of the Frontal lobes • Cortex above and below the operculum of the sylvian fissures • Lateral and inferior aspects of the temporal lobes

  32. Pathophysiology Medscape, Emedicine/ Merck Manual 2009 Primary Injury • Intracranial hematoma – most common cause of death and deterioration after TBI • Epidural – temporal bone fracture and MMA rupture • Subdural – rupture of bridging veins in the subdural space • Sub arachnoid – damage to blood vessels in the posterior fossa stalk

  33. Pathophysiology Medscape, Emedicine/ Merck Manual 2009 Primary Injury • Intracranial hematoma – most common cause of death and deterioration after TBI • Diffuse axonal injury – rotational acceleration of the brain • Defined clinically as LOC lasting > 6 hours in the absence of a specific focal lesion

  34. Pathophysiology Cellular destruction! Local edema Failure of ion pumps Intracellular Ca and Na overload hemorrhage Increased ICP Medscape, Emedicine/ Merck Manual 2009 • Secondary Injury • impairment or local declines in cerebral blood flow

  35. Pathophysiology Neuronal death!!! Free radical formation Release of excitatory amino acids Cells Die Proteolysis Lipid peroxidation Medscape, Emedicine/ Merck Manual 2009 • Secondary Injury • impairment or local declines in cerebral blood flow