ED trauma meeting 26th July 2012 C spine Bonanza Trauma Summary :June Snapshot 2 needed urgent intervention 114 Alerts 6 Responds 19 Missed activations Overall Disposition: ICU OT THDU NHDU IR ward 7 7 10 2 1 35 More than half are admitted; 20% are sick First half 2012 …. so far 2012 728 alerts 46 respond OT IR ICU ward Died in ED Case 1 I 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?? NEXUS 34069 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 2 3 4 5 6 7 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 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 3 Silly 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!!!