brain stem compression or hydrocephalus. Inthese patients, medical management alone often results in badoutcomes. Smaller cerebellar hemorrhages without brain stemcompression that are managed
medically do reasonably well. Outcome: The natural course of spontaneous ICH leads to a 30-day mortality rate of 45. The patients
initial level of consciousness, hemorrhage size, and intraventricular extension of blood has proven to be accurate predictors of outcome. Less commonly, age, sex, hypertension, and mass effect may indicate
harmful effects on outcome in patients with ICH.
The author recommends that patients with smaller hematomas who are alert, stable, or improving should be treated medically and the patients with larger hematomas who show progressive neurological
deficit, prolonged functional impairment, and intracranial hypertension should be treated surgically. Patientswith a GCS score 4 should also be treated medically because theyuniformly die or have
extremely poor functional outcome that cannotbe improved by surgery. Easily accessible supratentorial hematomas with mass effect, especially in the young and in those with a GCS score 5, must be
evacuated. The aim of surgery should be the removal of as much of the clot as possible, with minimal disruption of surrounding brain tissue. If possible,surgery should also remove the underlying cause of
hemorrhage, suchas an arteriovenous malformation, and prevent complicationsof ICH such as hydrocephalus and mass effect of the blood clot. Morecomplete clot removal may decrease elevated ICP
and local pressure effectsof the blood clot on the surrounding brain. Stereotacticaspiration may be associated with better outcomes than standardcraniotomy; but thishypothesis has yet to be tested in a
randomized study. Ultra-earlyremoval of ICH by localized, minimally invasive surgical proceduresis promising but untested. Further study of the dynamics of hemorrhage and additional results are needed
prior to making a decision on how to divide patient management into the two categories of surgical and nonsurgical treatment.
SCENARIO
Male patient, 50 years oldwas referred to the Emergency room on a face mask oxygenation, with Infusion lines at right arm with large caliber of needle, warmed crystalloids has been administered. The
blood pressure is 180100 mmHg, heart rate 60xmnt, Respiration rate 20xmnt. Pupil round an equal, size: right side 5mm, left side 3mm, with left hemi paresis. His eyes are open with pain stimuli and his
GCS was E2V2M4. History: When he was watching TV, suddenly he got severe headache, vomiting and then seizure. After that he looks decreased of consciousness. History of hypertension + since 5 years
ago, regularly take medication.
LEARNING TASKS
1. What is the clinical diagnosis and differential diagnosis? 2. What is the investigation that need for this patient?
3. How is the initial management for this patient? 4. When should you suggest to doing surgery for this patient?
5. How should you explain the prognosis of the patient to the family?
SELF ASSESMENT 1. Explain the Cerebrovascular Anatomy that supplies the brain and cerebellum.
2. Learn about clinical features, investigations and differentials diagnosis of cerebrovascular disease. 3. Learn about emergency management: medical and surgical aspect of CVA.
4. Learn about how to explain the prognosis of CVA.
Faculty of Medicine Udayana University, DME 61
DAY 10
th
June 2
nd
2014 SPINAL CORD INJURY, COMPLETE SPINAL TRANSECTION, ACUTE MEDULLA COMPRESSION
Dr. dr. Tjokorda GB Mahadewa, M.Kes, Sp.BSKSpinal
SPINAL CORD INJURY Aims:
Provide initial assessment and management, established tentative diagnosis, proposed definitive management, and rehabilitation method or refer patient with Spine and Spinal Cord Injury
Learning outcome: The student can provide initial assessment and management, established tentative diagnosis, proposed
definitive management, and rehabilitation method or refer patient with Spine and Spinal Cord Injury
Curriculum contents: Spine and Spinal Cord Injury:
4. Evaluate and appropriately manage for suspected Spinal Injury 5. Determine appropriate patient disposition and definitive management for Spinal Injury
6. Proposed rehabilitation method or refer patient with Spinal Injury
Abstracts of lectures
It is estimated that the prevalent population of people in America with a spinal cord injury SCI is approximately 200.000-400.000 people. The incidence is about 40 per million people and about 11.000
new cases per year. SCI is caused by both trauma and by disease processes non-traumatic SCI such as spinal cord infection and infarction. Mostly 50,7 affected cervical level, frequently at C5 level, using
American Spinal Cord Injury Association ASIA Impairment Scale is determined 49 in ASIA A Complete Impaired. Typically people who acquire a traumatic SCI are young and male, whilst non-traumatic SCIs
occur more often in later life and with a more even gender split. Most spinal cord injury causes permanent disability or loss of movement paralysis and sensation below the site of the injury. Paralysis that involves
the majority of the body, including the arms and legs, is called quadriplegia or tetraplegia. When a spinal cord injury affects only the lower body, the condition is called paraplegia. Many scientists are optimistic
that important advances will occur to make the repair of injured spinal cords a reachable goal. In the meantime, treatments and rehabilitation allow many people with spinal cord injury to lead productive,
independent lives.
Today, theres still no way to reverse damage to the spinal cord. But modern injuries are usually less severe, partial spinal cord injuries. And advances in recent years have improved the recovery of
people with a spinal cord injury and significantly reduced the amount of time survivors must spend in the hospital. Researchers are working on new treatments, including innovative treatments, prostheses and
medications that may promote nerve cell regeneration or improve the function of the nerves that remain after a spinal cord injury. In the meantime, spinal cord injury treatment focuses on preventing further injury
and enabling people with a spinal cord injury to return to an active and productive life within the limits of their disability. This requires urgent emergency attention and ongoing care.
Emergency actions Urgent medical attention is critical to minimizing the long-term effects of any head or neck trauma. So
treatment for a spinal cord injury often begins at the scene of the accident. If you suffer a head or neck injury, youll likely be treated by paramedics and emergency workers who will attend to three immediate
concerns:
Maintaining your ability to breathe
Keeping you from going into shock
Faculty of Medicine Udayana University, DME 62
Immobilizing your neck to prevent further spinal cord damage
Emergency personnel typically immobilize the spine as gently and quickly as possible using a rigid neck collar and a rigid carrying board, which theyll use to transport you to the hospital. In the emergency
room, doctors focus on maintaining your blood pressure, breathing and neck stabilization and avoiding possible complications, such as stool or urine retention, respiratory or cardiovascular difficulty, and
formation of deep vein blood clots in the extremities. You may be sedated so that you dont move and sustain more damage while undergoing diagnostic tests for spinal cord injury. If you do have a spinal cord
injury, youll usually be admitted to the intensive care unit for treatment. You may even be transferred to a regional spine injury center that has a team of neurosurgeons, orthopedic surgeons, spinal cord medicine
specialists, psychologists, nurses, therapists and social workers with expertise in spinal cord injury.
Early stages of treatment
In the early stages of paraplegia or quadriplegia, your doctor will treat the injury or disease that caused the loss of function. Immediate treatment may include:
Medications. Methylprednisolone Medrol is a treatment option for acute spinal cord injury. This
corticosteroid seems to cause some recovery in people with a spinal cord injury if given within eight hours of injury. Methylprednisolone works by reducing damage to nerve cells and
decreasing inflammation near the site of injury.
Immobilization. You may needtraction to stabilize your spine and bring the spine into proper
alignment during healing. Sometimes, traction is accomplished by placing metal braces, attached to weights or a body harness, into your skull to hold it in place. In some cases, a rigid
neck collar also may work.
Surgery. Often, emergency surgery is necessary to remove fragments of bones, foreign objects,
herniated disks or fractured vertebrae that appear to be compressing the spine. Surgery may also be needed to stabilize the spine to prevent future pain or deformity. Controversy exists
regarding the best time to perform surgery. Some surgeons believe it should be performed as soon as possible in most circumstances, while others believe its safer to wait for several days
before attempting any surgery. Research has not clearly proved which approach is better.
Persisting SCI impacts on every aspect of a persons life: health status, physiological, active community participation, psychological, social, reproductive, economic, employment, educational and
recreation. An SCI will affect people in variable ways, depending on the level of the spinal cord lesion and the completeness of the injury. Generally all people with SCI have some degree of motor or sensory loss
and a disrupted autonomic nervous system. This has a profound effect on a persons health, function and physiology. The most important factors predicting functional outcome are the neurological level and degree
of completeness of spinal cord lesion. However, a range of other medical and non-medical factors can influence outcome, including age, body shape and weight, associated injuries, pre-existing disease,
spasticity and contractures, living arrangements and family support, level of education and financial resources. Functional goals are based on sequential organization of spinal segments and capacity of
spared muscle groups to perform specific activities of daily living, qualified by other factors such as those listed above.
When working with patients to establish wheeled mobility goals, it is essential to understand the individual impact of a persons SCI and other health issues associated with co-morbid conditions and with
ageing. Pre-morbid lifestyle and interests, personality characteristics and coping style, degree of social support and economic circumstances will all be important factors influencing adjustment and eventual
outcome. Within the learning modules is information about establishing and assessing a patient’s health status. For people who require wheeled mobility, the effective prescription and use of a wheelchair enables
and empowers them to participate in life and interact in their community. Many patients with a spinal cord injury will spend most of their waking hours in their wheelchair; each patient is unique and has highly
individual and, over time, changing needs. It is no longer acceptable, if it every was, to prescribe a wheelchair and seating system without careful consideration of the patient’s goals and postural, pressure,
functional, safety and environmental needs. A correctly prescribed wheelchair and seating system will
Faculty of Medicine Udayana University, DME 63
optimize function, address the impact of environmental factors, correct and prevent postural and pressure issues and meet a patients community participation needs
Scenario
Male patient, 25 years old as a passenger of a public transportation, had a head on collision. The driver was died immediately at the scene. The patient was referred to the Emergency room as being
immobilized on a long spine board and semirigid cervical collar. On a face mask oxygenation, with Infusion lines at both arms with large caliber of needles, warmed crystalloids has been administered. The blood
pressure is 8540 mmHg, heart rate 130xmnt, Respiration rate 40xmnt, shallow respiration pattern, with an obvious injury on the chest wall. His eyes are open and well respond to verbal stimuli. He can lift up his
shoulder but cannot elevate his elbows neither his legs.
6. What is the working diagnosis? 7. How is the prompt management for this patient?
8. How should you explain the prognosis of the patient to the family?
Learning tasks 5. Learn about Initial Assessment and Management for Spinal Injury.
6. Learn about Spinal Injury diagnosis and management for Spinal Injury. 7. Learn about rehabilitation methods for Spinal Injury.
8. Learn about how to refer patient with Spinal Injury
