Servikal Spinal Kord Yaralanması Olan Hastada Yoğun Bakım Yönetimi: Olgu Sunumu
Özet
Yüksekten düşme nedeniyle C3 ve C4 servikal vertebrada burst fraktürü tanısı ve solunum sıkıntısı ile acil servisten yoğun bakım ünitesine (YBÜ) gelen hastayı sunmayı amaçladık. Hasta YBÜ’ye geldiğinde servikal boyunluk ile stabilize, takipneik (solunum sayısı 30/dk), dispneik, hipotansif (75/45mmHg) ve bradikardikti (45 atım/dk). Paraplejik olan hastanın üst ekstremitelerde duyu kaybı ile 3/5 motor gücü mevcuttu. Yutma güçlüğü eşlik ediyordu. Eşlik eden diğer organ yaralanması yoktu. Erken dönemde video laringoskop eşliğinde elektif orotrakeal entübasyon, kristalloid sıvı replasmanı, hemodinamik monitörizasyon, arter kateterizasyonu ile sürekli basınç monitörizasyonu, santral venöz basınç (CVP) takibi, ilk 8 saatte stabilizasyon cerrahisi, metilprednizolon tedavisi, profilaktik antibiyoterapi başlandı. Yatışının 7. gününde klinik olarak motor ve duyusal fonksiyonlarında düzelme görülmeyen hastaya perkütan trakeostomi açıldı. Yoğun bakım takibi boyunca nazogastrik sondadan enteral beslenme, mesane kateterizasyonu, pnömoni açısından antibiyotik profilaksisi , kas atrofisi ve kontraktürü açısından fizik tedavi egzersizleri ve basınç ülseri gelişimini önlemek için havalı yatak desteği, pulmoner emboli gelişimi açısından düşük molekül ağırlıklı Heparin (DMAH) ile profilaksi uygulandı. Yatışının 18. gününde hasta ev tip homeventilatör ile noninvaziv ventilasyon (NIV) desteği sağlanarak bilinç açık, koopere, oryante şekilde trakeostomili ve perkütan enteral gastrostomi (PEG) ile palyatif bakıma devredildi.
We present the case of a patient who visited the intensive care unit (ICU) from the emergency room with a diagnosis of burst fracture in the C3 and C4 cervical vertebrae and respiratory distress due to a fall from a height. When the patient arrived at the ICU, he was stabilized with a cervical collar, tachypnea (respiratory rate 30/min), dyspnea, hypotension (75/45 mmHg), and bradycardia (45 beats/min). The patient, who was paraplegic, had sensory loss in the upper extremities and motor power of 3/5. This was accompanied by difficulty swallowing. No accompanying organ injury was observed. In the early period, elective orotracheal intubation guided by a video laryngoscope, crystalloid fluid replacement, hemodynamic monitoring, continuous pressure monitoring with arterial catheterization, central venous pressure (CVP) monitoring, stabilization surgery in the first 8 h, methylprednisolone treatment, and prophylactic antibiotic therapy were initiated. On the 7th day of hospitalization, percutaneous tracheostomy was performed on the patient, whose motor and sensory functions did not show any clinical improvement. During the intensive care unit follow-up, enteral nutrition through a nasogastric tube, bladder catheterization, antibiotic prophylaxis for pneumonia, physical therapy exercises for muscle atrophy and contracture, air mattress support to prevent the development of pressure ulcers, and prophylaxis with low-molecular-weight heparin (LMWH) for the development of pulmonary embolism were administered. On the 18th day of hospitalization, the patient was transferred to palliative care with tracheostomy and percutaneous enteral gastrostomy (PEG) in a conscious, cooperative, and oriented manner, with noninvasive ventilation (NIV) support provided by a home ventilator.
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