Case of Paraplegia

A 30 year old male is brought in by paramedics with history of injury at rugby field. The patient describes the injury as forced forward flexion of body by someone dodging from behind and he fell to the ground, which was followed by some players falling on his back. After which he complained of no sensations or possible movements in his both lower limbs.

He lies on bed, and a primary survey indicates preserved A, B, and Cs. In examination of debility, we assess the sensory dermatomal distribution from the abdomen downwards, T10 at umbilicus, T12 at pubis, L1 at Inguinal ligament preserved. No sensation below this level (to dull and pin prick), no motor functions, loss of muscle tone, No DTRs. No sensations at scrotal skin, but tenderness on pressing the testicles. Log roll done to reveal tenderness and step deformity at L1, and loss of rectal tone.

(Picture courtesy: Netter's Atlas)

An X ray of the LS Spine is done and is displayed below:

The case demonstrates dermatomal approach to delineate the site of vertebral injury, and emphasizes on learning the dermatomal distribution of both the upper and lower limbs to be used in traumatic spinal injuries.

Case Study 3: Orthopedic Emergencies

55 year old male presents to ED with history of fall on right shoulder when his bike slipped on the freeway. He is concious and oriented, but complains of severe pain on right chest dorsally and shoulder region. His vitals are stable, and chest examination has normal findings, except for minor bruises near shoulder and back. The ED physician orders a CXR (AP/Lat) as the patient was in severe pain, and insisted on getting an X ray done. The X ray films are as below. What would be the diagnosis and management in the ED?

Case Study 2: Emergency Cardiology

78 year old lady approached the ED with complaints of shortness of breath for last 3 - 4 days. She is hypertensive lady with Moderate Aortic Stenosis for last several years on regular medical treatment. She is being treated with Ecosprin, Metaprolol, & Spironolactone. The relatives attending the patient added that her pulse was around 50's for last 2 -3 days which her family physician attributed to her beta blockers. She has no symptoms at present. Her BP is 90/70 mm Hg, and her pulse in 36/min. Her chest has bilateral crackles, but her saturation is 95 % on room air. The EKG rhythm is as shown below. Her serum electrolytes were within normal limits, and there was no acidosis on blood gas analysis readings. What is your diagnosis?

The lady was diagnosed to be in complete heart block. As she was hypotensive, 0.5 mg of intravenous Atropine was administered, but there was no response on her pulse and BP. Cardiology consult was done, and transcutaneous pacing was recommended. The transcutaneous pacing was not helpful and intravenous temporary pacing procedure was recommended. After obtaining informed consent, right IJV was cannulated under ultrasound guidance and pacing sheath introduced using Seldinger Technique under LA. The pacing wire was introduced, and patient was placed on temporary pacemaker (Sn 1.0, I 3.0 mA, Rate 70). Post procedure, patient's pulse was 70, BP 120/70. Patient was shifted to the CCU under the care of the attending cardiologist. Post procedure XRC, & EKG rhythm strip is as below:

Case Study 1: Respiratory Emergencies

35 yr old lady is admitted to the ED with complaints of SOB and cough for last 3 days. She is being treated with oral antibiotics for pneumonia by her GP. She suddenly develops respiratory distress and desaturates. The ED resident decides to intubate and mechanically ventilate the patient. Post intubation, air entry is found to be equal, and her saturations now are 95+ on FiO2 of 80. An XRC done as a protocol for post intubation is shown in the figure. What action must be taken at this moment?

a) Inform Respiratory Physician & Admit in ICU

b) Inform Respiratory Physician & Admit in Ward

c) Give injectable antibiotics

d) Reposition the tube

e) Increase FiO2 to 90 or 100 %, reduce TV, Give PEEP

f) Reduce TV, Give PEEP