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Trams plus alcohol = problem By Dr Cynthia Lim ED Physician The Northern hospital.

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Presentation on theme: "Trams plus alcohol = problem By Dr Cynthia Lim ED Physician The Northern hospital."— Presentation transcript:

1 Trams plus alcohol = problem By Dr Cynthia Lim ED Physician The Northern hospital

2 53 year old Caucasian male Brought in by ambulance Fell in tram and struck head against MIKI scanner, ?LOC Alcohol +++ Found GCS 6 – 11 then 13 on arrival ED C/o neck pain, moving all limbs Phx – unable to be obtained

3 In ED Hr 80, BP 80/- (palpated, auscultation limited by arm scarring) Triaged within 20min of arrival ATS 3 (2211hrs) GCS 13/15, HR 80, BP 130/-(?copied from ambulance). Trend was decreasing BP prior In monitored cubicle 2310hrs, log rolled onto bed with medical staff in attendance Initial GCS 13/15 (eyes shut,sl confused) HR 70 BP 61/44 Urgently moved to resus

4 Initial rapid ABC Airway – slurred speech, able to c/o pain neck and squeeze hands,C-collar in situ B SaO2 – 88% ra (99% 10L Hudson mask) C shocked! D – not moving legs!

5 Possible diagnosis? Immediate management priorities

6 ?Neurogenic shock vs. other traumatic causes shock Large bore IV both arms 2L stat N/saline followed Metaraminol boluses Adrenaline infusion started (concern re-possible bradycardia with neurogenic shock) Pt finally fully exposed for full trauma examination

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8 M

9 More definitive ABC A – GCS 13/15 (eyes shut, sl confused) B – paradoxical breathing due to extensive scarring from old burns, nil chest pain or clinical rib # C – HR 70-80, BP >90/- with inotropes D – extensive scarring from burns from below jaw down to mid abdomen circumferential to both sides, also both arms to hands Clinically fractured nose with small amount bleeding nostrils

10 D (continued) Neurological exam Complete sensory loss from down anterior torso Unable to move from elbow down (3+/5 elbow movements) Areflexic from elbow Abdomen - soft, no priapism, FAST – NAD – large bladder

11 Where to from here? We don’t have imaging yet…

12 Big airway risk GCS altered/ high chance of loss of airway protection through the “tunnel of doom” Bleeding from nose Probable C5/6 cord injury from acute fracture – mandatory in line immobilisation ‘No neck’ with extensive scarring down to chest – difficult surgical airway

13 Specialty consult Anaesthetics – difficult airway equipment Surgeon and ICU consultants called in for surgical airway Plan A and Plan B discussed prior attempted intubation

14 What actually happened First look with McGrath Laryngoscope blade - difficulty inserting blade as small mouth/restricted opening = grade iv view Blood and secretions +++ Aborted after suctioning then Guedel and bag valve mask ventilation 2 nd attempt – size 3 larygoscopy blade – Grade III view. I Intubated with Bougie successfully Escorted to pan CT

15 CT report There is opening of the intervertebral disc space anteriorly at the C6-C7 level indicative of anterior longitudinal ligament disruption. There are spinous process fractures of C5 and C6. There is a right C6 vertebral artery foramen fracture and an adjacent right C7 lateral mass-articular pillar fracture. There is narrowing of the central canal between the posterior aspect of C6 and the lamina of the C7 to a minimum of approximately 6 mm, and I suspect as a result cord impingementThere is opening of the intervertebral disc space anteriorly at the C6-C7 level indicative of anterior longitudinal ligament disruption. There are spinous process fractures of C5 and C6. There is a right C6 vertebral artery foramen fracture and an adjacent right C7 lateral mass-articular pillar fracture. There is narrowing of the central canal between the posterior aspect of C6 and the lamina of the C7 to a minimum of approximately 6 mm, and I suspect as a result cord impingement

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17 Rest of the story Rest of the story Transferred to Austin as spinal unit there Surgical fixation 2 days post transfer to enable future rehabilitation Poor prognosis as limited family support (family didn’t want to see pt), prior poor socioeconomical circumstances – alcohol abuse)

18 Systemic problems Ambulance ramp time Who takes responsibility of pt BP not checked for 45 min after triaged Allocation of triage category Lack of ENT expertise

19 Role of steroids/acute surgical tx NASCIS II and III – not recommended Some improvement motor but not functional Increased morbidity/mortality from steroid use Controversial re- acute (within 24 hours) vs. delayed surgical fixation Suggestion of some improvement function but increased incidence medical complications

20 Neurogenic shock Distributive shock from autonomic disruption in cervical/upper thoracic level Loss of sympathetic tone with decreased systemic vascular resistance and vasodilation Occasional bradycardia from unopposed vagal stimulation (esp if higher than C5 injuries)

21 Spinal shock Physiological Transient – days to weeks Flaccid paralysis Anaesthesia Loss of bladder/bowel function (priapism) Areflexia Replaced by hyperreflexia, inc tone

22 Acute spinal shock trauma Complete cord injury (this patient) Normal sensation/power at level of lesion Decreased level below Absent in levels thereafter Incomplete cord injury Variable dermatomal/myotomal loss Sensation better preserved than motor Anal sensation intact

23 Acute spinal shock trauma Central cord syndrome Greater upper limb vs. lower limb motor dysfunction Sensory loss variable Bladder dysfunction Hyperextension injury with cervical spondylolistheses

24 Anterior spinal cord syndrome Anterior spinal cord (disc herniation) Weakness, areflexia Loss of pain/temp Urinary incontinence Preserved dorsal columns (tactile/position/vibration sense)


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