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Case Presentation #3
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Case Presentation #3 - June 13, 2003 2:20:00 PM
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Dr.Wagner
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Joined: January 24, 2003
From: Indianapolis
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As you remember, a while back I posted cases...well, I rean into another interesting one the other day.
Remember, I give a bit of history and you guys ask DIRECT questions and you must give justifications for your reasons. This is a bit like residency.
I will start you off...by no means do I expect all the correct responses, as many of you do not practice in this setting...
28 year old white female is brought into the ED via helicopter after being involved in a MVC...car vs pole. She is a restrained driver found partially ejected.
She is stable and breathing on her own. She states "I can't feel my feet, I can't move anything"
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Re: Case Presentation #3 - June 13, 2003 3:27:00 PM
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flexion
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Interesting case - thanks Wagner. You'll have to excuse my lack of ER protocols here but this should be good for all of us.
How long since the accident until the patient presents?
No moving from neutral of this patient for now until we figure out grossly if there is cord involvement and extent of it. For the patient, what happened (ie. description of accident and CCs)? was there any head trauma or loss of consciousness?
Questions: What do you mean you can't by you can't move anything? Can she wiggle fingers and toes? If she isn't moving those fingers then need to lock down head/neck movement if not already done and get some c-spine x-rays or a CT/MR.
At the moment some kind of cervical cord transection is going through my mind which is below C4 (since diaphragm function still intact) but need some further Hx.
[This message has been edited by flexion (edited June 13, 2003).]
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Re: Case Presentation #3 - June 13, 2003 5:00:00 PM
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DcK
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Let's leave the C-Collar/backboard in place, do a global inspection checking for lacerations, brusing, fractures, swelling, etc., check pupils, check for sensory deficiences, check reflexes, palpate for tenderness globally and c-spine, see if in fact motor function on extremites is intact, order blook workup, order xrays... make sure ABC's stay clear.
[This message has been edited by DcK (edited June 13, 2003).]
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Re: Case Presentation #3 - June 13, 2003 8:52:00 PM
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prohealth
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Hi, just joined this forum...
Doc Wagner:
Here are a few questions, I have in mind:
1. Time of MVA/ case brought in? Night may be suggestive to the cause-poor vision, drinking, etc. Time elapsed since the accident may be indicative to the prognosis depending upon the current state of the patient.
2. Blood test results- ETOH/ drug levels?
3. Fractures/ lacerations especially- trunk/ abdominal area secondary to steering wheel position? (May give us an indication of the level of spinal cord injury). Attend to open wounds/ lacerations rightaway to prevent massive blood loss.
4. Status of airbag when rescued? Speed of the car- may be indicative of damage expected.
5. Diaphragmatic function seems intact- but their could be incomplete spinal cord injury (that is not apparent right away) or, at least lower than C4. Also, may be the response time of the paramedics was so quick, that she has not yet developed the response to the insult-i.e, increased intra-cranial pressure, cerebro-spinal pressure due to edema, etc, and thus "appears" to be normal at least mentally by verabilizing, while this might not be true. With the impact she may have had a forced flexion-extension injury of the cervical vertebrae (whip lash) severing the spinal cord/diffused axonal injury (?- has she lost motor and sensory functions of both upper and lower extremities or just lower? Or is she just saying she 'cannot move anything' because she is currently under immobilization applied by the EMTs or just shocked/scared after the accident? Either way, no immobilization should be removed till her complete X-Ray/ CT scan/MRI results are back.
6. A complete neuro-check must be done.She may have had a concussion/ coup/contre-coup effect on the brain due to impact (any visible signs on the head? swelling- hydrocephalus yet,although CHI not apparent as yet? CT scan/MRI results? Per hx. was she found conscious, did she lose consciousness at all till now? Any amnesia? Mental status-confusion/ disorientation? PERL? Any seizure activity noticed thus far- even petitmal kind?
7. What's her cardiac status? Rhythmic pulse? Does she need a sedative? Oxygen saturation? Hypoxia indicative of TBI (hippocampal)?
8. Spinal tap- CSF examination, if motor/ sensory functions affected?
9. Any body else available (if anything was found in the car/ her relatives were contacted) to give any psycho-social history- suicide attempt? Although not an ED issue right now, but critical for the ICU/ acute rehab process that I believe starts almost immediately following the ED's interventions.
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Re: Case Presentation #3 - June 13, 2003 9:24:00 PM
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axon
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From: Illinois, USA
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hi Dr W,
Questions:
Is she alert/ awake?
Any mental status changes?
Is she intoxicated?
Does she have any neck pain or distracting pain?
Any neurologic deficits?
Will wait and keep the hard collar on/ spine board, until these questions are answered.
Thanks!
Sam Betts
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Re: Case Presentation #3 - June 14, 2003 4:42:00 AM
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Dr.Wagner
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From: Indianapolis
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She already has a c-collar on, and is strapped on a back board.
She speaks and states "I cant move my legs...I can't feel them", upper extremity movement is intact.
Glasgow Coma Scale is 15.
ABC's...Airway clear and intact, able to protect. Breathing symetrical bilat, no wheezes, rhonchi, rales rate of 21. Circulation intact...no obvious lacerations, cap refill is 1-2 sec, good pulses in all extremities. Heart rate and rhythm regular.
Vitals: 130/75, hr 98, rr 21, o2 sat 96% on room air.
You look at the EMT and find out that her car was destroyed. She was a restrained driver, no airbag.
No family has arrived.
You ask the patient about the accident, she states "I just ran into the pole somehow, I was going 45 or so and ran into the pole...why can't I feel my legs!??"
AMPLE history:
Allergies:none
Meds: none
PMHx: appendectomy, tonsillectomy, knee surgery
Last meal: Lunch today
Event: as stated
Alot of people want to do alot of things...one thing at a time. Can't do everything at once...so I NEED AN ORDER OF EVENTS. DcK is on the right track.
I know some of you want tests...blood is being drawn.
What blood tests do you want?(trick question)
How much of the physical exam should we perform? Leave her restained or take off the buckles on the back board? Leave her on or off the back board? C collar on or off for testing?
Pain meds or is she in pain?
Somebody wanted to sedate her...why?...would that compromise our neuro exam? Somebody mentioned a spinal tap...why...how?
[This message has been edited by Dr.Wagner (edited June 14, 2003).]
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Re: Case Presentation #3 - June 14, 2003 8:24:00 AM
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DcK
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>>>What blood tests do you want?(trick question)
I don't know. I'd assume the standard trauma blood panel, but I don't know specifically what that includes?
>>>How much of the physical exam should we perform?
I'm concerned of loss of consciousness, she doesn't seem very coherent based on your writings? I'd want to check to see of motor function is working to lower extremities, pin prick test to see if in fact sensory function is not working in lower extremities, palpate lumbar spine for tenderness, check lower extremity reflexes.
>>>Leave her restained or take off the buckles on the back board?
For heavens sake, leave her w/backboard and c-collar on for now. Take xrays with all of it on.
>>>Leave her on or off the back board? C collar on or off for testing?
Leave it all on while testing.
>>>Pain meds or is she in pain?
Her vitals look okay for now, no pain meds until you figure out whats going on. She's probably in pain, her pulse is high, but I don't know, is she screaming in pain? [IMG]http://www.rehabedge.com/forums/smile.gif[/IMG] Even if she's screming in pain, hold off for now.
>>>Somebody wanted to sedate her...why?...would that compromise our neuro exam?
No sedation please.
>>>Somebody mentioned a spinal tap...why...how?
No spinal taps please.
Just tell us what the neuro exam, palpation, and what xrays revealed... and someone tell me what more about the blood workup in a trauma setting? (After xrays... what's next? I'd suspect CT if xrays are negative and she has no motor or sensory??) [IMG]http://www.rehabedge.com/forums/smile.gif[/IMG]
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Re: Case Presentation #3 - June 14, 2003 11:52:00 AM
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prohealth
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1. Blood test- I guess to determine intoxication, anemia/ need for transfusion due to blood loss?
2. Seems like her upper body is doing fine, so I am assuming injury T12 or lower.
3. Sedation only if neurological functions are deemed uncompromised (obviously after a complete neuro-check/ physical) . I guess may be a muscle relaxant is appropriate, just to calm her down (if it seems she is only anxious/ shocked by the event).
4. Spinal tap- for presence of blood will be indicative of brain hemmorhage. To be taken only after neurological impairments is evident. GCS currently suggests no brain injury though. Seems more like a T12 or below SCI injury case.
Sequence:
1. AMPLE; blood test simultaneously
2. Complete physical exam- vitals/ neuro-check
3. X-Ray- proceed to CT/ MRI
4. Seems pulmonary/ cardio-vascular functions intact. No punctures/ injury to the internal organ thus far- urine test? Any hematuria?
5. Proceed to other tests if hunched on SCI, TBI
6. Reduction of fractures if needed, pain management/ reduce anaxiety as needed, if not complicating with level of consciousness. With a perfect GCS, the chances are paraplegia and ofcourse, a very shocked/ anxious patient is a great possibility.
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Re: Case Presentation #3 - June 14, 2003 3:27:00 PM
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Bournephysio
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From: Calgary
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How was she partially ejected? Through the windshield? Where is her pain?
I would ask if she was pregnant and test the blood for it. (heard that pregnancy could hide some pathology if blood is shunted from the fetus)
I would also do a tox screen on the blood and check for csf proteins ( can you do that?) You can't do a spinal tap without moving the patient which you can't do until you have cleared the spine.
Test for abdominal pain.
Test leg sensation and ask her to wiggle toes.
I'm not sure if it would be better to do a quick x-ray and then target the CT or go straight to CT.
I'm guessing it will probably be a Tsp fracture dislocation from levering over the seatbelt. I'm a concerned that she didn't know how she ran into the pole.
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Re: Case Presentation #3 - June 14, 2003 9:07:00 PM
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axon
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From: Illinois, USA
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She has complaints of neurological deficit and the reason for her accident is unclear; maybe due to a preceeding neurological event, causing her leg anaesthesia.
I would do a tox screen/ blood alcohol first as a blood test to see why she crashed her car.
If she may have neuro history then she may be unable to complain of neck pain, or sense neck pain-----> leave the collar on.
Lateral and AP x-rays including an open mouth a must, if any suspicion of neuro deficit.
Also may need thin cut axial CT-scan of C1-2 if unable to visualise the upper cervical spine well.
If x-rays and CT negative, but she still has neuro deficit, perform an MRI while still immoblized.
Lets do those tests first in order, pending necessity as outlined.
We need to rule out life threatening fracture/ dislocation before removing that collar and testing further.
Sam B
[This message has been edited by axon (edited June 15, 2003).]
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Re: Case Presentation #3 - June 15, 2003 4:48:00 AM
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Andrew M. Ball PT PhD
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From: Charlotte, NC
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I agree that the C-Collar/backboard should remain in place until we know more
1. Do a global inspection
2. Ortho/Neuroscreen (can she move her toes?)
3. Imaging to clear cervical spine, any fractures? I'm concerned about possible dens fracture (and so an open mouth radiograh), but while were down there in radiology, I'd want to take an AP and Lateral peek at the lumbar spine too.
4. Blood work for tox screening, but first I want to know if you smell alchohol on her breath or if she exhibits any signs of drug use?
5. Do you get the feeling that this single-care accident may have been a suicide attempt, and if so, is a neuropsych referal appropriate once her medical condition has stabilized?
Also, in some states Narcan injection is a standard practice of the EMT's in cases where they assume that the patient may have been drunk and/or on specific classes of rec drugs. Did she get a Narcan injection?
Drew
[This message has been edited by Andrew M. Ball PT PhD (edited June 15, 2003).]
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Re: Case Presentation #3 - June 15, 2003 7:45:00 AM
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Dr.Wagner
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From: Indianapolis
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Everyone seems to be on the same page...This presentation is in REAL TIME
You keep the C-collar on and perform the Primary survey...
To make a long story short Head and neck are benign with the exception of a small amount of blood from the nares, otherwise completely normal, pupils are reactive and equal.
Chest is normal
Upper extremities are normal
Abdomen is normal and without tenderness.
Pelvis is stable
Rectal tone is good without gross blood
Lower extremities are pristene, with what appears to be hyper-reflexia of L4
There is no babinski
Anesthesia from the iliac crest down. There is NO lower extremity movement...except for a TINY bit of right great toe "wiggles".
C-spine radiographs are fine, Dens is ok...what other xrays do you want?
Would you like to follow them up with CT's...if so anything more than C1-2?
Anyone want to put in a Foley Catheter first?...ok it was done in order to get the urinalysis.
As the medical student in the trauma bay you ask "hey can I do a Spinal Tap?" The attending looks at you like you have a giant wart on your face and says "now, if you do a spinal tap prior to a CT you stand the chance of Uncal herniation...also, how am I supposed to to a spinal tap if the patient must stay in spinal neutral and we can't flex the spine??" You slowly walk away realizing, you don't need a spinal tap.
Standard trauma labs are drawn, CBC is back...wbc's 13000, hgb 13, hct 35, platelets 200000
UA= no etoh, not pregnant
patient is stable, vitals normal
talking, not in pain, anxious but appropriate
In addition to the above questions...do you wish to call anyone?
I do not smell alcohol.
I do not get the impression drugs are on board.
This was a single car accident.
Partially ejected= arm and head hanging outside of drivers side window when the EMT's arrived.
As the medical student in the trauma bay, you ask "Should we use narcan??"
The attending looks at you like you have an even bigger wart on your face and asks "what are the indications for Narcan?"
[This message has been edited by Dr.Wagner (edited June 15, 2003).]
[This message has been edited by Dr.Wagner (edited June 15, 2003).]
[This message has been edited by Dr.Wagner (edited June 15, 2003).]
[This message has been edited by Dr.Wagner (edited June 15, 2003).]
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Re: Case Presentation #3 - June 15, 2003 8:06:00 AM
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Bournephysio
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From: Calgary
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We need Tsp and Lsp radiographs as well. Followed by CTs.
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Re: Case Presentation #3 - June 15, 2003 8:35:00 AM
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DcK
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Dam xray techs, where's my lumbar films? Why the heck would you take c-spine w/out lumbars, you said her upper extremites where fine & she can't move her lower extremities... I ORDERED LUMBAR FILMS.. Where are they? [IMG]http://www.rehabedge.com/forums/smile.gif[/IMG]
I want to see lumbar/pelvic films and we may follow that w/CT. As soon as I see the films, we'll probably need to call orthopods or neurologists, depending on what my dam films say!
Typically, do ER doc's consult orhto/neuro's PRIOR to a CT? I think I've read that somewhere, but I could be wrong... and I'd assume the protocals vary slightly from hospital to hospital.
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Re: Case Presentation #3 - June 15, 2003 9:27:00 AM
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flexion
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Well she still has a cord it appears but I'm thinking something is not happy T12-L2 ballpark. Could be some swelling, blood or damage in there along corticospinal tract? Stroke is also in the back of my mind but not as high up on the list.
Definitely need the lower T-spine/upper L-spine MRI and a neurosurgeon ASAP.
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Re: Case Presentation #3 - June 15, 2003 12:28:00 PM
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Dr.Wagner
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From: Indianapolis
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Standard films are
C-spine, chest and pelvis...you get all three and they are OK...nothing, nada.
You order T-spine, and LS-spine all normal no fractures or dislocations.
You decide to get on the phone to neurosurgery because this is a spinal trauma case and TYPICALLY (though this is debated in EM and trauma circles) dexamethasone is started to decrease swelling around the cord.
So that is started also...
Ok, so we head to CT with our stable patient...what exactly do we want to CT? Remember mechanism.
Also, there is a question re: narcan, I believe Drew asked it...no, it is NOT appropriate to use narcan as this patient shows no evidence of opiate overdose. It should only be used in OD cases or the "unconcsious unknown" patient.
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Re: Case Presentation #3 - June 15, 2003 1:02:00 PM
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DcK
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Wow, all plain films are negative.
>>"Ok, so we head to CT with our stable patient...what exactly do we want to CT? Remember mechanism."
Okay, the is so far beyond my scope... but I'm thinking you'd want a CT of the head first.
Very good case!
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Re: Case Presentation #3 - June 15, 2003 2:19:00 PM
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Diane
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If she was restrained AND still partially ejected something must have stretched pretty far, even if no bones were broken.
If she was restrained I'm thinking a huge sudden stretch to the lumbosacral plexus could leave her feeling quite paralyzed, just as a brachial plexus overstretch would. (I'm thinking of motorcycle accidents where the arm is still there although it doesn't work anymore.)
So might this be a "peripheral" nervous system disruption? (I wouldn't have a clue how to find that, or what to do in what order...just a guess.)
Diane
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Re: Case Presentation #3 - June 15, 2003 2:55:00 PM
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prohealth
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Me too, beyond my scope by far, but interesting to at least imagine work in the ED...No idea about the CT mechanism. Assuming no fractures of any bones whatsoever per radiographs already available. Agree w/ DcK CT of the thoracic/ lumbar spine and also of the head (just to r/o head injury completely) still maintaining the spinal neutral position? Should I be concerned with the leucocytosis or is that normal for trauma/ stress cases such as this? With plantar response absent, assuming DTR (knee/ ankle)diminshed/ absent, it is indicative of a LMN lesion. Does the dexamethasone work to facilitate return of any movement/ sensation post reduction of swelling? (I am assuming we wouldn't know for another 2-4 hours). With the patient cardio-vascular/ pulmonary functions WFL, and waiting on the neurosurgeon and CT results, shouldn't I start the patient with a prophylactic ATB therapy? Okay, now that the neurosurgeon is in, let me focus on another case :-)
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Re: Case Presentation #3 - June 15, 2003 6:06:00 PM
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flexion
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Well if we are off to CT then head and another centered T12-L2. I'm still thinking its a cord problem and not a brain problem but getting ejected should warrant and head CT since she must have went through some window with her head.
That twitching though in the one foot does bother me a bit (lateral corticospinal tract)... maybe we have 2 lesions here. Is there any clonus in the quads on that twitching side?
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