Many thanks to everyone who has visited and "liked" our Facebook site at www.facebook.com/drolimedonthego/. As usual this blog post is available in podcast form; you can access the podcast episode by the link in the previous post or by going to www.medonthego.podbean.com. Subscribe to us on iTunes, Google Play, or Podbean to make sure you never miss an episode! If you've enjoyed either my podcast or compiled medical notes, please consider supporting me by becoming a patron; for more details please visit www.patron.podbean.com/medonthego.
For patients presenting after significant fall (> 12ft),
deceleration injuries, blunt trauma to head, neck, or back, assume cord injury.
Spinal immobilization such as spinal collar and transportation via spine board
is to be undertaken until spinal injury can be ruled out. Sometimes vertebral
injuries can be sustained without spinal cord injury, and a normal neurologic
exam does not rule out spinal injury. Sometimes the spinal cord can be injured
despite normal C-spine x-ray (SCIWORA = spinal cord injury without radiologic
abnormality). The injuries can include complete/incomplete transection, cord
edema, and spinal shock.
Any spinal cord injury below T10 à beware Cauda Equina Syndrome!
Symptoms include incontinence, anterior thigh pain, quadriceps weakness,
abnormal sacral sensation, decreased rectal tone, and variable reflexes.
History:
·
Mechanism of injury
·
Previous deficits
·
Neck pain, weakness/paralysis, paresthesia
Physical exam:
·
Vital signs
·
Abdominal: ecchymosis, tenderness
·
Complete neurological examination, including
mental status
·
Spine:
o
Front—palpate C-spine while maintaining neutral
position
o
Back—log roll to palpate T and L-spine and
assess rectal tone
o
When palpating, assess for tenderness, muscle
spasm, bony deformities, step-off, and spinous process mal-alignment.
·
Extremities: capillary return, suspect
thoracolumbar injury with calcaneal fractures (e.g. patient falling from height
landing on his/her feet).
Investigation:
·
Blood work: CBC, electrolytes, creatinine,
glucose, coagulation profile, cross and type, and toxicology screen.
·
Imaging
o
C-spine x-ray series (AP, lateral, odontoid)
o
Thoracolumbar x-ray series (AP, lateral) if any
of the following is present:
§
C-spine injury
§
Unconscious patient (and probable mechanism of
injury)
§
Patients with neurological symptoms or findings
§
Patients with palpable deformities when log
rolled
§
Patients with back pain
§
Patients with bilateral calcaneal fractures
(concurrent burst fractures of the thoracic or lumbar spine T11~L2 will be find
in 10%)
o
Consider CT for subtle bone injuries
o
Consider MRI for soft tissue injuries
C-Spine can be cleared when:
·
Oriented to person, place, time, and event
·
No intoxication
·
No posterior midline cervical tenderness
·
No focal neurological deficits
·
No painful distracting injuries (so that patient
neglects to recognize pain from neck).
Management of cord injury
·
Immobilize
·
DRABC
·
Treat neurogenic/spinal shock (maintain systolic
BP > 100)
·
NG tube and Foley catheter
·
High dose steroids (methylprednisolone 30mg/kg
bolus, then 5.4mg/kg/h drip within 6~8 h after injury) is controversial and
recently has less support
·
Complete imaging of spine and consult spine
service if available
·
Continually assess high cord injuries as edema
can travel up cord
·
If there is cervical cord injury, watch out for
respiratory insufficiency
o
Low cervical transection (C5~T1) produces
abdominal breathing (phrenic innervation of diaphragm still intact).
o
High cervical injury (C4 and above) may require
intubation and ventilation
·
Supportive treatment: warm blanket,
Trendelenburg position (the
body is laid supine with the feet higher than the head by 15-30 degrees),
volume infusion, consider vasopressors.
No comments:
Post a Comment