ed trauma meeting 26 th july 2012 c spine bonanza
TRANSCRIPT
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ED trauma meeting
26th July 2012
C spine Bonanza
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Trauma Summary :June Snapshot
114 Alerts
6 Responds
19 Missed activations
2 needed urgent
intervention
Overall Disposition:
ICU 7OT 7 THDU 10NHDU 2IR 1ward 35
More than half are admitted; 20% are sick
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First half 2012
…. so far 2012
728 alerts
46 respond
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Case 1I think you call this a clusterf***
1004917
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Prehospital
Monday 4th June 08:45
M struck by motorcyclist who lost control of his bike I bone protruding (L) lower leg
S alert, HD stable decreased pulses in foot T Ketamine 100mg, morphine 10mg # reduced and splinted, soft collar
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Emergency Dept 10:17
Airway & Breathing ✔
Circulation ✔ Disability ✔
Clinically Head, Neck, Abdo & pelvis – fairly unremarkable
Predominately lower limb issues:
L)leg deformed ankle, sml 2mm open wound neuro/vasc intact
R) leg abrasion over medial ankle + lower leg
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CXR
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L lower limb
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Initial ED management
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Orthopaedic ward
10/5 Physio notes C-spine limited right rotation & lateral flexion (suggest stretches for C-spine)
11/5 C/O pins & needles in R) index + mid fingers
Care transferred to plastics 18th May
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Plastics ward
– 18/5 OT: free flap to L) lower leg
– 19/5↓ SpO2 85% RA, seen by ward call
– 20/5 CTPA : no PE, # 8th rib seen by plastics reg C-spine Xray (to investigate paraesthesiae) ortho review suggesting CT spine (shooting pain
shoulder/neck)
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CT C-spine
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Back to orthopaedic ward
– 22/5
Tertiary Survey XR R) ankle medial malleolus #
– 26/5
OT ACDF C6-C7 + R) medial malleolus ORIF
– 13/6
Discharged home Day 28
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Clinically clearing a C-spine
How do you do it??
Do decision rules help??
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NEXUS34069 patients (included children)
99% sensitivity
Virtually no risk of C-spine injury if:
NEXUS criteria met:– No neurology, normal alertness– Not intoxicated– No midline tenderness– No distracting painful injury
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What is a distracting injury?
What does NEXUS say???
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Canadian C-spine Rule8924 adult patients
100% sensitivity
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Now we have decided to do an Xray ……How do we
interpret it?
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Anatomy refresher: C1 anatomy
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C2 anatomy
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C4 anatomy
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Lateral view
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Adequacy
7
2
3
4
5
6
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Lines
Anterior
Vertebral
Line
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Lines
Posterior
Vertebral
Line
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Lines
Spinolaminal
Line
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Lines
Posterior Spinous
Line
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Spaces
Pre-dental space
< 5mm children
< 2.5mm adults
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Soft tissue
< ⅓ width of C2
< full width of C7
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Peg view
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Check bony landmarks
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Symmetry of lateral dens space
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Check the lateral tips of C1
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Some abnormal C spines
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Case 2Thank God for Short Stay
196315
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CT head
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CT C-spine
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Issues
• Old people break stuff look for it
• Good news is they hardly ever have to do anything about it
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Case 3Silly people break things too
816340
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Prehospital
Monday 4th June 18:02
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Emergency : Resus 4
Primary survey ✔
– C-spine nil central tenderness
(ETOH on board)
– Mild abrasions to L shoulder
– CXR & C-spine NAD
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CXR
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C-spine
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Our Plan
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What do you do??
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Represents
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What next?
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CT result
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Outcome
• Orthopaedic admission
• Rest of spine imaged on the ward– T 12 anterior wedge #– Free fluid in pelvis
• Halo brace fitted, discharged d4
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Issues raised• The intoxicated patient has an
unreliable examination
• If you order tests make sure you check them in a timely fashion
• If you find a spinal # look for more
• DOCUMENTATION!!!