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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!!!