Ariel Kravitz Senior Seminar March 5, 2014 Basic Science Advisor: Dr. Marnie FitzMaurice Clinical...
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Transcript of Ariel Kravitz Senior Seminar March 5, 2014 Basic Science Advisor: Dr. Marnie FitzMaurice Clinical...
VEHICULAR POLYTRAUMA IN A CAVALIER KING CHARLES
SPANIEL PUPPYAriel Kravitz
Senior Seminar March 5, 2014
Basic Science Advisor: Dr. Marnie FitzMauriceClinical Advisor: Dr. Chelsie Estey
OUR PATIENT
Signalment 13 wo FI CKCS
Not vaccinated Previously diagnosed with Bordetella
Day 2 of Amoxicillin/Clavulanic acid
1 DAY PRIOR TO PRESENTATION TO CUHA
Unsupervised outside Good Samaritan witnessed the vehicular trauma
and brought her to an ER/CC center Treated for shock and cerebral edema Kept overnight - no improvement
PRESENTATION TO CUHA EMERGENCY
Initial assessment Vocalizing in pain when moved → methadone Mild hypoxemia (SpO2: 21%: 92-93%) Hypotensive (96/58) (MAP 72) → fluid bolus T FAST → negative A FAST → negative Parvovirus SNAP test → negative
PRESENTATION TO CUHA EMERGENCY
Neurologic examination Mental Status: Bright, Alert, Responsive Attitude/Posture: Slightly hunched posture Conformation/Muscularity: Normal Gait: Non ambulatory paraparesis (with minimal motor) Cranial Nerves: Normal Proprioception: Absent in pelvic limbs Spinal Reflexes: normal thoracic limb reflexes; decreased
withdrawal reflexes bilaterally in the pelvic limbs; decreased patellar reflexes on the right and absent on left; normal cutaneous trunci reflex on the right but cutoff at L3 on the left
Nociception: lumbar discomfort
PRESENTATION TO CUHA EMERGENCY
Neurologic examination Mental Status: Bright, Alert, Responsive Attitude/Posture: Slightly hunched posture Conformation/Muscularity: Normal Gait: Non ambulatory paraparesis (with minimal motor) Cranial Nerves: Normal Proprioception: Absent in pelvic limbs Spinal Reflexes: normal thoracic limb reflexes; decreased
withdrawal reflexes bilaterally in the pelvic limbs; decreased patellar reflexes on the right but absent on left; normal cutaneous trunci reflex on the right but cutoff at L3 on the left
Nociception: lumbar discomfort
PRESENTATION TO CUHA EMERGENCY
Neurologic examination Mental Status: Bright, Alert, Responsive Attitude/Posture: Slightly hunched posture Conformation/Muscularity: Normal Gait: Non ambulatory paraparesis (with minimal motor) Cranial Nerves: Normal Proprioception: Absent in pelvic limbs Spinal Reflexes: normal thoracic limb reflexes; decreased
withdrawal reflexes bilaterally in the pelvic limbs; decreased patellar reflexes on the right but absent on left; normal cutaneous trunci reflex on the right but cutoff at L3 on the left
Nociception: lumbar discomfort
Neurolocalization: T3-L3 and L4-S3 myelopathy
PRESENTATION TO CUHA EMERGENCY
Plan Full body CT Restrained on a backboard in O2 cage Supportive care in ICU Transfer to the Neurology Service in the AM
FULL BODY CT- HEAD
Transverse soft tissue window post-contrast Coronal bone window post-contrast
FULL BODY CT- HEAD
Transverse soft tissue window post-contrast Coronal bone window post-contrast
FULL BODY CT- HEAD
Transverse soft tissue window post-contrast Coronal bone window post-contrast
FULL BODY CT- CERVICAL VERTEBRAE
Sagittal bone window
FULL BODY CT- CERVICAL VERTEBRAE
Sagittal bone window
FULL BODY CT- THORAX
Transverse soft tissue window
FULL BODY CT- THORAX
Transverse soft tissue window
FULL BODY CT- LUMBAR VERTEBRAE
Transverse bone window through L4 Sagittal bone window throughL3-L5
FULL BODY CT- LUMBAR VERTEBRAE
Transverse bone window through L4 Sagittal bone window throughL3-L5
Transverse bone window through L3
PROBLEM LIST
Comminuted fracture of L4 vertebra Fissure fracture of C3 vertebra Bilateral pulmonary contusions Fractures of the right orbit Fractures of the frontal sinus with pneumocephalus
and intracranial hemorrhage Hypoxemia Bordetella positive
VEHICULAR POLYTRAUMA
High energy blunt injury Trauma - 2nd most common cause of death Most common cause of vertebral fractures
2nd spinal fracture/luxation - ~20% Additional injuries – 40-50%
PE findings more sensitive than radiographs
Figure 2 from Evaluation of vehicular trauma in dogs: 239 cases (January-December 2001)
SPINAL TRAUMA
Pathophysiology 1o injury
Immediate result of the trauma Mechanical damage to the spinal cord → physical disruption
of neuronal and glial cell membranes 2o injury
Hours to days following trauma Biomechanical processes triggered by the primary injury →
worsening spinal cord damage
SPINAL TRAUMA
Pathophysiology 1o injury
immediate result of the trauma Mechanical damage to the spinal cord → physical disruption
of neuronal and glial cell membranes 2o injury
Hours to days following trauma Biomechanical processes triggered by the primary injury →
propagated spinal cord damage
PRIMARY SPINAL CORD INJURY
3 compartment model Boney and soft tissue structures
Dorsal Middle Ventral
If 2 of the 3 compartments are affected → unstable injury
Figure 12.1 from A Practical Guide to Canine and Feline Neurology
GOALS OF SPINAL MANAGEMENT
Prevent ongoing primary injury and allay perpetuation to secondary injury
Stabilization of a fracture is based on: The damaged structures The forces acting on them
VERTEBRAL FRACTURE REPAIR
Goals Realign and stabilize the spinal column Decompress the spinal cord
Surgical techniques Pins + PMMA* Locking plates * External fixators* Vertebral body plates Modified segmental fixation Tension band stabilization Spinous process plating
VERTEBRAL FRACTURE REPAIR
Goals Realign and stabilize the spinal column Decompress the spinal cord
Surgical techniques Pins + PMMA* Locking plates * External fixators* Vertebral body plates Modified segmental fixation Tension band stabilization Spinous process plating
L4 VERTEBRAL FRACTURE REPAIR Dorsal laminectomy
Dorsal decompression Visualize L4 vertebral fracture
Cortical screw placed transarticularly through the R articular facet joint of L4
4 screws placed bicortically through L3 and L5 Screws placed through the base of L and R transverse processes of L3 Screw placed through the base of the L transverse process of L5 Screw placed through the R transverse process and pedicle of L5
PMMA with cefazolin molded around the screws
Fig. 35-6 from Small Animal Surgery
POST-OP CT
Transverse bone window through L5
Sagittal bone window through L2-L5
POST-OP CT
POST-OP TREATMENT
Treatment 40% O2 Plasmalyte + 1.5% dextrose Fentanyl CRI Ampicillin/Sulbactam Ceftazidime Ondansetron, Pantoprazole and Sucralfate
DAY 1 POST-OP PROGRESS
Neurologic examination – Day 1 post-op Ambulatory paraparesis with voluntary motor function in
all limbs Absent placement in the hindlimbs bilaterally Intact withdrawal, patellar and perineal reflexes Cutaneous trunci reflex cutoff at the level of L3 on the
left; normal on the right Continue to improve in hospital Oxygen independent day 3 post-op Fluids tapered and switched to all oral medication
DAY 5 POST-OP
TGH Medications
Cefpodoxime Amoxicillin/Clavulanic acid Pregabalin Tramadol Metronidazole
Exercise restriction At home rehabilitation
PROGNOSIS
Fair to good Comminuted fracture - L4 Vertebra
Failure of perfect anatomical alignment - potential for the spinal cord to be compressed if the fragments dislodge from their current locations
60-70% chance to return to normal function Fissure fracture - C3 Vertebra
Not at issue at this time Potential for neurologic deficits in the future
Growing Trauma
PROGNOSIS
Bilateral pulmonary contusions – improving Fractures of the right orbit
Not at issue at this time Unknown in future
Fractures of the frontal sinus with pneumocephalus and intracranial hemorrhage Not at issue at this time Unknown in future Predisposed to seizures
RECHECK 1
4 weeks post-op Neurolocalization: Thoracolumbar spine (T3-L3)
Mild hindlimb spinal ataxia Absent postural thrust on the right, delayed on the left,
normal placing in all four limbs Pain elicited on head palpation, cranial cervical and
thoracolumbar spine Spinal radiographs
RECHECK 1- SPINAL RADIOGRAPHS
RECHECK 1
Prognosis Still fair to good
Recommendation: Medications
Pregabalin Tramadol
Exercise restriction At home rehabilitation
RECHECK 2
10 weeks post-op Neurolocalization: Thoracolumbar spine (T3-L3)
Mild hindlimb spinal ataxia Delayed hopping on the right pelvic limb, normal
hopping in other limbs, normal placing in all four limbs
No pain elicited on palpation Spinal radiographs
RECHECK 2 - SPINAL RADIOGRAPH
RECHECK 2
Prognosis Good!
Recommendation: Medications
Pregabalin (tapered dose for 1 week) Tramadol
Exercise restriction
COST IN HOSPITAL
Initial Stay
ECC exam $113.00
Full body CT $733.00
Surgery + Anesthesia $2078.26
Supportive therapy +maintenance in ICU x 9 days $4254.34
Total $7178.60
4 Week Recheck
Exam + Radiographs $220.40
10 Week Recheck Exam + Radiographs $200.00
Total Cost $7599.00
SELECTED REFERENCES Dewey, C. A Practical Guide to Canine & Feline Neurology. 2nd ed. pp 405-
414. Wiley-Blackwell, 2008. Ames, Iowa. Fleming J.M. et al. Mortality in north american dogs from 1984 to 2004: an
investigation into age-, size-, and breed-related causes of death. Journal of Veterinary Internal Medicine. 2011 Mar. 25(2), pp 187-98.
Fossum , T. Small Animal Surgery. 1st ed. pp 1118-1127. Mosby and Co., 1997. St. Louis, Missouri.
Olby, N. The pathogenesis and treatment of acute spinal cord injuries in dogs. 2010 Sep. 40(5), pp791-80.
Rockar, R.A et al. Development a Scoring System for the Veterinary Patient. Journal of Veterinary Emergency and Critical Care. 2007 Jul. 4 (2), pp 77-83.
Streeter, E. et al. Evaluation of vehicular trauma in dogs: 239 cases (January–December 2001). JAVMA. 2009 Aug. 235 (4), pp 405-408.
Tobias K, Johnston S: Veterinary Surgery: Small Animal. 1st ed. pp 487-496. Elsevier/Sauders, 2012. St. Louis, Missouri.
THANK YOU
Dr. Chelsie Estey Dr. Marnie FitzMaurice Dr. Sofia Cerda-Gonzalez My family Class of 2014
QUESTIONS?