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
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
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)