ED trauma meeting 26 th July 2012 C spine Bonanza

Trauma Summary :June Snapshot 114 Alerts 6 Responds 19 Missed activations 2 needed urgent intervention Overall Disposition: ICU 7 OT 7 THDU 10 NHDU2 IR 1 ward35 More than half are admitted; 20% are sick

First half 2012 …. so far alerts 46 respond

Case 1 I think you call this a clusterf***

Prehospital Monday 4 th 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 18 th 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??

NEXUS 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 Rule 8924 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

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 2 Thank God for Short Stay

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 3 Silly people break things too

Prehospital Monday 4 th 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!!!