You will find examples of Word and Powerpoint write ups - they are the same as on the PBL website.
PBL Learning Issue Example : The following is well written and highly referenced – and should help give you a concrete idea of what a nicely done write up looks like. Word count = 744.
Author: Fred – Group 11 – PBL 1 – 9/6-9/10 Case: A man with a spinal injury
Question: What is the current treatment and associated prognosis for an injured spinal cord?
Spinal cord injury is most commonly caused by trauma. Other causes include infarction, hemorrhage, and acute disc herniation. Current practices for treating spinal cord injury are generally to prevent further damage to the spinal cord (1, 2).
Treatment includes immobilization of the entire spine for transport of the patient to a medical facility. The patient should be rapidly delivered to the closest spine center as delays increase morbidity. Unstable patients
should simply be taken to the closest hospital. Immobilization reduces the risk of further damage to the spinal cord (2).
An airway is also established depending on the level of the injury as respiratory function may be impaired.
The more superior the injury, the greater is the indication for airway intervention. Any patient with an injury superior to C5 should be intubated. In general, an orotracheal intubation is performed. Nasal intubation, although not preferred, can be performed on patients with spinal immobilization. Virtually all patients with cervical spine trauma require sedation for proper nasal intubation (2).
Injury of the spinal cord often leads to sympathetic denervation. There is a loss of alpha-1 activity causing dilation of arteries, and a loss of beta-1 activity causing bradycardia and reduced cardiac contractile strength.
This ultimately leads to hypotension. This is treated with fluid replacement. It is important to note that after
a traumatic event, hemorrhage should come before spinal cord damage on the differential for the hypotension (2).
Steroids are also used to treat spinal cord injury. Treatment should begin within 8 hours of the injury. Initially a 30 mg/kg bolus of methylprednisolone is administered IV over 15 minutes followed by a
45 minute pause. This is, in turn, followed by continued application via IV of methylprednisolone at 5.4
mg/kg for an additional 23 hours. This has been shown to improve motor and sensory function in patients after blunt trauma. Methylprednisolone is believed to work by inhibiting free radical-mediated neuron membrane damage. Other beneficial mechanisms include increased spinal cord blood flow, increased extracellular calcium, and reduced potassium loss from the damaged nerves (2, 3).
Surgery can also be used to treat spinal cord injuries. In some cases, realignment of the spine may be necessary through surgical manipulation. Also, in cases such as gun shot wounds, surgery may be needed to
remove pieces of bone or other foreign bodies such as shrapnel. This is indicated if the foreign body is in the
spinal canal or causes a hematoma which leads to a progressive decline in function. If the spine is unstable, surgery may be performed to stabilize the vertebrae by spinal fusion with metal plates, rods, and/or screws (2, 4).
Within 72 hours to 1 month after a spinal cord injury, it is possible to reasonably predict the recovery of a patient. A comprehensive physical examination, and the initial location and severity of the
injury are the most accurate measures of ultimate functional capability. MRI can also be helpful. Acutely,
20% of traumatic spinal cord injuries are fatal. Patients with complete motor and sensory loss at 72 hours are very unlikely to recover function beyond one root below initial site of injury. 90% of patients with
incomplete transections of the spinal cord can ambulate a year after the injury. The ultimate extent of the loss of function after spinal cord injury is highly variable (4, 5, 6).
Relevance to Case-
After the jump, Bill has lost sensation at his torso (1-2 inches below his collar bone), chest, back, abdomen, legs, and the medial aspect of his arm to his elbows. This represents a loss of sensation from dermatomes T1 and below. Bill also notes that his thumbs and fingers are weak. His digits relate to
dermatomes C6-C8. This information indicates that his spinal cord is severely damaged at somewhere above
T1 and also is affected at the C6-8 segments.
Bill was immobilized to reduce the chance of further spinal cord injury. He was not intubated as he had proper respiratory function, although his spinal cord may be damaged at the cervical level. He seemed to
be still very active, and so is probably not very hypotensive. Methylprednisolone was administered in an
appropriate manner to increase the chances of recovery functional recovery. He was immediately evacuated to a medical center to increase his likelihood of recovery and survival. Surgery may be indicated if he has an unstable spine, or loose bone fragments from the fall.
References-
1. Jason E Decker, MD, Albert C Hergenroeder, MD; Overview of cervical spinal cord and cervical peripheral nerve injuries in the young athlete; ©2006 UpToDate
2. Judith E. Tintinalli, MD, MS, et al; EMERGENCY MEDICINE: A Comprehensive Study Guide; Chapter 256. Spinal Cord Injuries; Copyright © 2004
3. Nesathurai S.; Steroids and spinal cord injury: revisiting the NASCIS 2 and NASCIS 3 trials.; J Trauma. 1998 Dec;45(6):1088-93.
4. Gerard M. Doherty, Lawrence W. Way; Current Surgical Diagnosis and Treatment, 12th Edition; Chapter 37. Neurosurgery & Surgery of the Pituitary; Copyright © 2006
5. Burns AS, Ditunno JF.; Establishing prognosis and maximizing functional outcomes after spinal cord injury: a review of current and future directions in rehabilitation management. Spine. 2001 Dec 15;26(24 Suppl):S137-45.
6. Kirshblum SC, O'Connor KC.; Predicting neurologic recovery in traumatic cervical spinal cord injury.; Arch Phys Med Rehabil. 1998 Nov;79(11):1456-66.
Courtesy of: Geffen UCLA School of Medicine
References:
