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!!!