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Abstract: Patient Li, 38 years old, was out shopping 1 day ago and was cut by a small car while walking resulting in head trauma, headache, dizziness, nausea and vomiting. She was sent to the emergency department by 120 and diagnosed with traumatic subarachnoid hemorrhage by imaging. After clear diagnosis, further hospitalization was required. The patient’s condition improved through inpatient observation, infusion therapy such as nerve nutrition, and Chinese medicine rehabilitation treatment.
Basic information】Female, 38 years old
Type of disease】Traumatic subarachnoid hemorrhage
Hospital】Qingdao Traditional Chinese Medicine Hospital
Consultation date】May 2022
Treatment plan】Infusion therapy (naloxone hydrochloride injection + vitamin B6 injection + cytarabine sodium injection + mannitol injection) + TCM rehabilitation therapy (auricular pressure pills, acupressure points, foot bath, acupuncture)
[Treatment Period] 2 weeks in hospital
Treatment effect】The condition has been significantly improved, and all indicators have improved
I. Initial consultation
The patient, Ms. Li, was out shopping 1 day ago, and fell to the ground when she was cut by a car while walking, and the right side of her body and head landed on the ground, causing head injury and local skin rupture and bleeding. The patient was examined by the emergency physician. The patient was in a trance, with obvious nausea and vomiting, and the muscle strength of the limbs was somewhat reduced.
II. Treatment process
Combining the patient’s main symptoms and cranial CT examination results, the diagnosis of head trauma and traumatic subarachnoid hemorrhage was clear, and the relevant laboratory test results were improved immediately after admission. The patient was treated with vitamin B6 injection for nerve nutrition and cytarabine sodium injection for improving neurological function. At the same time, the patient’s liver and kidney function, electrolytes, coagulation mechanism and other tests were combined to maintain the balance of the internal environment.
On the second day of admission, the patient’s CT was routinely reviewed, and the CT results showed that his intracranial hemorrhage had improved compared with before, and his mental status had improved. He complained of headache discomfort, and was given mannitol injection for dehydration and decongestion, and at the same time contacted the TCM department to start TCM rehabilitation and recovery treatment, including treatment with auricular pressure pills, acupressure points, foot bath, and acupuncture. At the same time, an appointment was made for cranial MR examination, which showed no brain contusion and complete absorption of intracranial subarachnoid hemorrhage.
III. Treatment effect
After 2 weeks of comprehensive treatment, the patient’s symptoms were significantly improved, her mental state improved, her spirit improved significantly, her limbs moved well, she could move to the floor by herself, and she completely resumed her self-care life. The patient’s mental status improved significantly and he was discharged from the hospital, and he has returned to work normally after discharge.
IV. Notes
We are glad that the patient resumed normal work and life after treatment. It is recommended that after the patient is discharged, he should pay attention to a nutritious and healthy diet, carry out balanced exercises to enhance his physical quality, such as walking, Tai Chi and other exercises, and also quit smoking and alcohol to promote further physical recovery. In case of uncomfortable symptoms, such as headache, dizziness, nausea, vomiting, blurred vision, abnormal movement of limbs, etc., return to the hospital in time for medical consultation.
V. Personal insights
1, head injury accompanied by head pain, nausea and other discomfort, can not be ruled out whether there is intracranial injury, bleeding, must be the first time to go to the hospital for consultation.
2, such as this case, after examination, found a small amount of bleeding, need further hospitalization, regular re-examination, to improve the symptoms of treatment, and at the same time combined with Chinese medicine rehabilitation treatment, will achieve better results.
3, the current treatment of traumatic subarachnoid hemorrhage can be conservative, if combined with traumatic conditions such as cerebral contusions and heavy craniocerebral injuries, surgical treatment is required, which requires neurosurgeon assessment and further treatment.
4.After the healing of traumatic subarachnoid hemorrhage, patients can generally recover completely, but there are still a small number of patients with certain head discomfort, which requires outpatient follow-up and can take relevant oral medications to improve neurological function, which can eventually be improved.