ED trauma meeting 26 th July 2012 C spine Bonanza
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Transcript of ED trauma meeting 26 th July 2012 C spine Bonanza
ED trauma meeting
26th July 2012
C spine Bonanza
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
First half 2012
…. so far 2012
728 alerts
46 respond
Case 1I think you call this a clusterf***
1004917
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
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
CXR
L lower limb
Initial ED management
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
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)
CT C-spine
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
Clinically clearing a C-spine
How do you do it??
Do decision rules help??
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
What is a distracting injury?
What does NEXUS say???
Canadian C-spine Rule8924 adult patients
100% sensitivity
Now we have decided to do an Xray ……How do we
interpret it?
Anatomy refresher: C1 anatomy
C2 anatomy
C4 anatomy
Lateral view
Adequacy
7
2
3
4
5
6
Lines
Anterior
Vertebral
Line
Lines
Posterior
Vertebral
Line
Lines
Spinolaminal
Line
Lines
Posterior Spinous
Line
Spaces
Pre-dental space
< 5mm children
< 2.5mm adults
Soft tissue
< ⅓ width of C2
< full width of C7
Peg view
Check bony landmarks
Symmetry of lateral dens space
Check the lateral tips of C1
Some abnormal C spines
Case 2Thank God for Short Stay
196315
CT head
CT C-spine
Issues
• Old people break stuff look for it
• Good news is they hardly ever have to do anything about it
Case 3Silly people break things too
816340
Prehospital
Monday 4th June 18:02
Emergency : Resus 4
Primary survey ✔
– C-spine nil central tenderness
(ETOH on board)
– Mild abrasions to L shoulder
– CXR & C-spine NAD
CXR
C-spine
Our Plan
What do you do??
Represents
What next?
CT result
Outcome
• Orthopaedic admission
• Rest of spine imaged on the ward– T 12 anterior wedge #– Free fluid in pelvis
• Halo brace fitted, discharged d4
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!!!