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Case Study #2: MVC

Case Study #3
by

Robert Baginski

on 26 May 2016

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Transcript of Case Study #2: MVC

History of Present Illness:
Chief Complaint:
Ivana and her husband are on the way back from the airport after renewing their wedding vows in the "McMarriage Wedding Chapel" in Las Vegas then honeymooning in Mexico. You are working an evening shift. Ivana was wearing her seatbelt and is uninjured. However, her husband, a 33 year old male, was not restrained and is brought into the ED by EMS.
Radiology
X-Rays
Ancillary Studies
Hematology
Medical History:
PMH
:
Hypertension
Atrial fibrillation
(diagnosed 2 weeks ago)
No surgical history
No traumatic history

Meds
:
Metoprolol
Coumadin
Lisinopril

Allergies
: Strawberries
"The Case of the Irresistible Force vs. the Immovable Object"
Case #2
Other
Studies

Medical History
HPI
P.E.
Physical Exam
Coags
Urinalysis
Chemistries
Liver Function Tests
Cardiac Enzymes
Toxicology
AST: 25
ALT:

33
Total Bili: 1.1
Direct Bili:
0.3
Ammonia: 5
CK:
CKMB:
Troponin I:
PT: 19.1
PTT: 35
INR: 2.5
ETOH: <10
Urine Tox: neg
APAP: <2.0
ASA: 0
CT Scans
Ultrasounds
MRI
C-Spine
Radiology
Differential
Diagnosis

Interventions
11.5
39.5
13.1
255
Segmented neutrophils: 82%
Band forms: 1
Basophils: 0
Eosinophils: 1
lymphocytes: 16
Monocytes: 4
136
4.1
105
22
12
1.0
134
Color:
Pale yellow
Turbidity:
Clear
Specific Gravity:
1.020
pH:
5.0
Glucose:
Negative
Ketones:
Trace
Blood:
Negative
Protein:
Negative
Bilirubin:
Negative
Urobilinogen:
0.1-1.0
Nitrates:
Negative
Leukocyte Esterase:
Negative
Casts:
None
Red Blood Cells:
0-10
White Blood Cells:
0-10
Epithelial Cells:
2-10
Amylase: 45
Lipase: 12
Other Labs
Cervical spine fracture
Spinous process
Body
Transverse process
Lamina
Cervical spine subluxation
Cervical spine strain
Herniated cervical disc


FINAL
DIAGNOSIS
Epidural hematoma
:
Admission
Conservative management
Observation
Repeat imaging
q6 hours (or so)
Keep NPO
Reversal of anticoagulation
Stop coumadin
Vitamin K
FFP
Surgical evacuation if deteriorating
Not needed in this case...
Normal heart, no cardiomegaly, no infiltrates, pneumothorax, or free air.

Left anterior rib fractures of 7th and 8th ribs
Abnormal positioning of some of the facet joints due to distraction but no dislocation
Additional fracture of the body of C4
The vertical orientation of the fractures of the bodies of C4 and C5 indicate that there was severe axial loading.
(In fact these vertebral bodies kind of 'exploded' with propulsion of a bone fragment anteriorly (teardrop) and the larger part posteriorly against the spinal cord.)

Interventions:
Teardrop Fracture:
Spinal immobilization
Admission
NPO
Spinal surgery consultation
MRI
Analgesics
Closed reduction under fluoroscopy
Halo vest immobilization
Possible surgical immobilization
Flexion teardrop fracture of C5
EKG
Oriented to person, place time
Arrives walking normally, rubbing his neck

HEENT
: EOMI, PERRLA, sclera non-icteric
Ecchymoses to midline, anterior forehead, No deformity to calvarium
Pharynx and nares are normal
No hemotympanum
Neck
: tender in midline posteriorly over C4-C6
Tender over bilateral trapezium muscles, no deformity. Range of Motion (?)
Chest
: No deformity, normal excursion, no ecchymoses, tender to
Lungs
: CTAB
CV
: irregular rhythm, S1S2 without gallop, rub, or murmur
Abdomen
: soft, NT, no ecchymoses or abrasions, normal BS
Ext
: no deformities or tenderness or ecchymoses, Pulses 2+ throughout bilaterally
Back
: nontender in midline and to paraspinous muscles
Neuro
: No facial asymmetry, CN 2-12 intact
Motor and sensory intact throughout, non-focal exam
Your patient was not wearing his seat belt when his car was hit from behind 30 minutes ago. He says he was stopped at a red light when this happened. He doesn't really remember the collision, and the first thing he can recall afterward is waking up with a sore neck while the paramedics were knocking on the window. He quickly regained consciousness and unlocked the door. The neck pain is described as sharp. He has no prior neck problems or any other injury, nor does he have any chest pain, shortness of breath, abdominal pain, or problems with his extremities.
Not necessary in this case...

However, a FAST exam may be indicated...
Fracture of the body of C5 with a small fragment anteriorly
Fracture of the spinous processus of C4
Acute angulation at the level of C5C6 with displacement of C5 in posterior direction

This is known as a _______ ________ fracture
Head
Intracranial hemorrhage
Epidural hematoma
Subdural hematoma
Subarachnoid hemorrhage
Cerebral contusion
Coup-contracoup
Scalp contusion/soft tissue
injury

Epidural hematoma
1 PPD smoker for 12 years
Has 4 alcoholic drinks per week
Denies any non-prescription drug use
Sexually active with girlfriend. Monogamous for 5 years. Uses condoms...usually
Job: Aeronautical engineer

Family History
:
Father with HTN, CAD, MI at age 44
Mother: NIDDM, Gout

Social History
Vital Signs:
Temp: 37.0 C (98.6 F)
BP: 160/90 mmHg
HR: 110/min, irregular
RR: 20/min
O2 Sat: 97% on RA
Full transcript