Transcript Vehicular Polytrauma in a Cavelier King Charles Puppy

Ariel Kravitz
Senior Seminar
March 5, 2014
Basic Science Advisor: Dr. Marnie FitzMaurice
Clinical Advisor: Dr. Chelsie Estey
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Signalment
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13 wo FI CKCS
Not vaccinated
Previously diagnosed with Bordetella
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Day 2 of Amoxicillin/Clavulanic acid
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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
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Initial assessment
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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
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Neurologic examination
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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
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Neurologic examination
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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
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Neurologic examination
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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
Neurolocalization:
T3-L3 and L4-S3 myelopathy
 Nociception: lumbar discomfort
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Plan
Full body CT
 Restrained on a backboard in O2 cage
 Supportive care in ICU
 Transfer to the Neurology Service in the AM
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Transverse soft tissue window post-contrast
Coronal bone window post-contrast
Transverse soft tissue window post-contrast
Coronal bone window post-contrast
Transverse soft tissue window post-contrast
Coronal bone window post-contrast
Sagittal bone window
Sagittal bone window
Transverse soft tissue window
Transverse soft tissue window
Transverse bone window through L4
Sagittal bone window throughL3-L5
Transverse bone window through L4
Transverse bone window through L3
Sagittal bone window throughL3-L5
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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
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High energy blunt injury
Trauma - 2nd most common cause of death
Most common cause of vertebral fractures
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2nd spinal fracture/luxation - ~20%
Additional injuries – 40-50%
PE findings more sensitive
radiographs
than
Figure 2 from Evaluation of vehicular trauma in dogs: 239
cases (January-December 2001)
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Pathophysiology
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1o injury
 Immediate result of the trauma
 Mechanical damage to the spinal cord → physical disruption
of neuronal and glial cell membranes
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2o injury
 Hours to days following trauma
 Biomechanical processes triggered by the primary injury →
worsening spinal cord damage
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Pathophysiology
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1o injury
 immediate result of the trauma
 Mechanical damage to the spinal cord → physical disruption
of neuronal and glial cell membranes
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2o injury
 Hours to days following trauma
 Biomechanical processes triggered by the primary injury →
propagated spinal cord damage
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3 compartment model
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Boney and soft tissue structures
 Dorsal
 Middle
 Ventral
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If 2 of the 3 compartments are affected → unstable
injury
Figure 12.1 from A Practical Guide
to Canine and Feline Neurology
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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
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Goals
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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
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Goals
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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
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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
Transverse bone window
through L5
Sagittal bone window through L2-L5
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Treatment
40% O2
 Plasmalyte + 1.5% dextrose
 Fentanyl CRI
 Ampicillin/Sulbactam
 Ceftazidime
 Ondansetron, Pantoprazole and Sucralfate
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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
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Continue to improve in hospital
Oxygen independent day 3 post-op
Fluids tapered and switched to all oral medication
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TGH
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Medications
 Cefpodoxime
 Amoxicillin/Clavulanic acid
 Pregabalin
 Tramadol
 Metronidazole
Exercise restriction
 At home rehabilitation
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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
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Fissure fracture - C3 Vertebra
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Not at issue at this time
Potential for neurologic deficits in the future
 Growing
 Trauma
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Bilateral pulmonary contusions – improving
Fractures of the right orbit
Not at issue at this time
 Unknown in future
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Fractures of the frontal sinus with
pneumocephalus and intracranial hemorrhage
Not at issue at this time
 Unknown in future
 Predisposed to seizures
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4 weeks post-op
Neurolocalization: Thoracolumbar spine (T3-L3)
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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
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Prognosis
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Still fair to good
Recommendation:
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Medications
 Pregabalin
 Tramadol
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Exercise restriction
At home rehabilitation
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10 weeks post-op
Neurolocalization: Thoracolumbar spine (T3-L3)
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Mild hindlimb spinal ataxia
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Delayed hopping on the right pelvic limb, normal
hopping in other limbs, normal placing in all four
limbs
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No pain elicited on palpation
Spinal radiographs
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Prognosis
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Good!
Recommendation:
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Medications
 Pregabalin (tapered dose for 1 week)
 Tramadol
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Exercise restriction
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
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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 18798.
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 487496. Elsevier/Sauders, 2012. St. Louis, Missouri.
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Dr. Chelsie Estey
Dr. Marnie FitzMaurice
Dr. Sofia Cerda-Gonzalez
My family
Class of 2014