Trams plus alcohol = Trams plus alcohol = problemproblem

By Dr Cynthia LimBy Dr Cynthia Lim

ED PhysicianED Physician

The Northern hospitalThe Northern hospital

53 year old Caucasian 53 year old Caucasian malemale

Brought in by ambulanceBrought in by ambulance

Fell in tram and struck head against MIKI Fell in tram and struck head against MIKI scanner, ?LOCscanner, ?LOC

Alcohol +++Alcohol +++

Found GCS 6 – 11 then 13 on arrival EDFound GCS 6 – 11 then 13 on arrival ED

C/o neck pain, moving all limbsC/o neck pain, moving all limbs

Phx – unable to be obtainedPhx – unable to be obtained

In EDIn ED

Hr 80, BP 80/- (palpated, auscultation limited by arm Hr 80, BP 80/- (palpated, auscultation limited by arm scarring)scarring)

Triaged within 20min of arrival ATS 3 (2211hrs)Triaged within 20min of arrival ATS 3 (2211hrs)

GCS 13/15, HR 80, BP 130/-(?copied from GCS 13/15, HR 80, BP 130/-(?copied from ambulance). Trend was decreasing BP priorambulance). Trend was decreasing BP prior

In monitored cubicle 2310hrs, log rolled onto bed with In monitored cubicle 2310hrs, log rolled onto bed with medical staff in attendancemedical staff in attendance

Initial GCS 13/15 (eyes shut,sl confused) HR 70Initial GCS 13/15 (eyes shut,sl confused) HR 70

BP 61/44BP 61/44

Urgently moved to resusUrgently moved to resus

Initial rapid ABCInitial rapid ABC

Airway – slurred speech, able to c/o pain neck Airway – slurred speech, able to c/o pain neck and squeeze hands,C-collar in situand squeeze hands,C-collar in situ

B SaO2 – 88% ra (99% 10L Hudson mask)B SaO2 – 88% ra (99% 10L Hudson mask)

C shocked!C shocked!

D – not moving legs!D – not moving legs!

Possible diagnosis? Possible diagnosis? Immediate Immediate management prioritiesmanagement priorities

?Neurogenic shock vs. ?Neurogenic shock vs. other traumatic causes other traumatic causes shockshock

Large bore IV both armsLarge bore IV both arms

2L stat N/saline followed2L stat N/saline followed

Metaraminol boluses Metaraminol boluses

Adrenaline infusion started (concern re-possible Adrenaline infusion started (concern re-possible bradycardia with neurogenic shock)bradycardia with neurogenic shock)

Pt finally fully exposed for full trauma Pt finally fully exposed for full trauma examinationexamination

http://youtu.be/mJ_FYwUqzsM

More definitive ABCMore definitive ABC

A – GCS 13/15 (eyes shut, sl confused)A – GCS 13/15 (eyes shut, sl confused)

B – paradoxical breathing due to extensive B – paradoxical breathing due to extensive scarring from old burns, nil chest pain or clinical scarring from old burns, nil chest pain or clinical rib #rib #

C – HR 70-80, BP >90/- with inotropesC – HR 70-80, BP >90/- with inotropes

D – extensive scarring from burns from below jaw D – extensive scarring from burns from below jaw down to mid abdomen circumferential to both down to mid abdomen circumferential to both sides, also both arms to handssides, also both arms to hands

Clinically fractured nose with small amount Clinically fractured nose with small amount bleeding nostrilsbleeding nostrils

D (continued)D (continued)

Neurological examNeurological exam

Complete sensory loss from down anterior Complete sensory loss from down anterior torsotorso

Unable to move from elbow down (3+/5 elbow Unable to move from elbow down (3+/5 elbow movements)movements)

Areflexic from elbowAreflexic from elbow

Abdomen - soft , no priapism,Abdomen - soft , no priapism,

FAST – NAD – large bladder FAST – NAD – large bladder

Where to from here?Where to from here?We don’t have imaging We don’t have imaging yet…yet…

Big airway riskBig airway risk

GCS altered/ high chance of loss of airway GCS altered/ high chance of loss of airway protection through the “tunnel of doom”protection through the “tunnel of doom”

Bleeding from noseBleeding from nose

Probable C5/6 cord injury from acute fracture – Probable C5/6 cord injury from acute fracture – mandatory in line immobilisationmandatory in line immobilisation

‘‘No neck’ with extensive scarring down to chest – No neck’ with extensive scarring down to chest – difficult surgical airwaydifficult surgical airway

Specialty consultSpecialty consult

Anaesthetics – difficult airway equipmentAnaesthetics – difficult airway equipment

Surgeon and ICU consultants called in for surgical Surgeon and ICU consultants called in for surgical airwayairway

Plan A and Plan B discussed prior attempted Plan A and Plan B discussed prior attempted intubationintubation

What actually happenedWhat actually happened

First look with McGrath Laryngoscope blade - First look with McGrath Laryngoscope blade - difficulty inserting blade as small mouth/restricted difficulty inserting blade as small mouth/restricted opening = grade iv viewopening = grade iv view

Blood and secretions +++Blood and secretions +++

Aborted after suctioning then Guedel and bag valve Aborted after suctioning then Guedel and bag valve mask ventilationmask ventilation

22ndnd attempt – size 3 larygoscopy blade – Grade III attempt – size 3 larygoscopy blade – Grade III view. Iview. I

Intubated with Bougie successfullyIntubated with Bougie successfully

Escorted to pan CTEscorted to pan CT

CT report CT report • There is opening of the intervertebral There is opening of the intervertebral

disc space anteriorly at the C6-C7 level disc space anteriorly at the C6-C7 level indicative of anterior longitudinal indicative of anterior longitudinal ligament disruption. There are spinous ligament disruption. There are spinous process fractures of C5 and C6. There is process fractures of C5 and C6. There is a right C6 vertebral artery foramen a right C6 vertebral artery foramen fracture and an adjacent right C7 lateral fracture and an adjacent right C7 lateral mass-articular pillar fracture. There is mass-articular pillar fracture. There is narrowing of the central canal between narrowing of the central canal between the posterior aspect of C6 and the the posterior aspect of C6 and the lamina of the C7 to a minimum of lamina of the C7 to a minimum of approximately 6 mm, and I suspect as a approximately 6 mm, and I suspect as a result cord impingementresult cord impingement

Rest of the storyRest of the story

Transferred to Austin as spinal unit thereTransferred to Austin as spinal unit there

Surgical fixation 2 days post transferSurgical fixation 2 days post transfer

to enable future rehabilitationto enable future rehabilitation

Poor prognosis as limited family support (family Poor prognosis as limited family support (family didn’t want to see pt), prior poor socioeconomical didn’t want to see pt), prior poor socioeconomical circumstances – alcohol abuse)circumstances – alcohol abuse)

Systemic problemsSystemic problems

Ambulance ramp timeAmbulance ramp time

Who takes responsibility of ptWho takes responsibility of pt

BP not checked for 45 min after triagedBP not checked for 45 min after triaged

Allocation of triage categoryAllocation of triage category

Lack of ENT expertiseLack of ENT expertise

Role of steroids/acute Role of steroids/acute surgical txsurgical tx

NASCIS II and III – not recommendedNASCIS II and III – not recommended

Some improvement motor but not functionalSome improvement motor but not functional

Increased morbidity/mortality from steroid use Increased morbidity/mortality from steroid use

Controversial re- acute (within 24 hours) vs. Controversial re- acute (within 24 hours) vs. delayed surgical fixationdelayed surgical fixation

Suggestion of some improvement function but Suggestion of some improvement function but increased incidence medical complicationsincreased incidence medical complications

Neurogenic shockNeurogenic shock

Distributive shock from autonomic disruption in Distributive shock from autonomic disruption in cervical/upper thoracic levelcervical/upper thoracic level

Loss of sympathetic tone with decreased Loss of sympathetic tone with decreased systemic vascular resistance and vasodilationsystemic vascular resistance and vasodilation

Occasional bradycardia from unopposed vagal Occasional bradycardia from unopposed vagal stimulation (esp if higher than C5 injuries)stimulation (esp if higher than C5 injuries)

Spinal shockSpinal shock

PhysiologicalPhysiological

Transient – days to weeksTransient – days to weeks

Flaccid paralysisFlaccid paralysis

AnaesthesiaAnaesthesia

Loss of bladder/bowel function (priapism)Loss of bladder/bowel function (priapism)

AreflexiaAreflexia

Replaced by hyperreflexia, inc toneReplaced by hyperreflexia, inc tone

Acute spinal shock Acute spinal shock traumatrauma

Complete cord injury (this patient)Complete cord injury (this patient)

Normal sensation/power at level of lesionNormal sensation/power at level of lesion

Decreased level belowDecreased level below

Absent in levels thereafterAbsent in levels thereafter

Incomplete cord injuryIncomplete cord injury

Variable dermatomal/myotomal lossVariable dermatomal/myotomal loss

Sensation better preserved than motorSensation better preserved than motor

Anal sensation intactAnal sensation intact

Acute spinal shock Acute spinal shock traumatrauma

Central cord syndromeCentral cord syndrome

Greater upper limb vs. lower limb motor Greater upper limb vs. lower limb motor dysfunctiondysfunction

Sensory loss variableSensory loss variable

Bladder dysfunctionBladder dysfunction

Hyperextension injury with cervical Hyperextension injury with cervical spondylolisthesesspondylolistheses

Anterior spinal cord Anterior spinal cord syndromesyndrome

Anterior spinal cord (disc herniation)Anterior spinal cord (disc herniation)

Weakness, areflexiaWeakness, areflexia

Loss of pain/tempLoss of pain/temp

Urinary incontinenceUrinary incontinence

Preserved dorsal columns Preserved dorsal columns (tactile/position/vibration sense)(tactile/position/vibration sense)