A 50 year old man is brought into the Emergency Department after acute flexion injury to the neck while surfing. He is unable to move both arms or legs and has a sensory level at C4·5. He ls a heavy smoker with a history of chronic bronchitis.
(a) Outline your initial management.
Candidates failed to understand the effects of a C4-5 lesion. There has obviously been a quick assessment of the patient so that we are told of paralysis and sensory level. Being a surfing injury, and not a high speed MVA, associated injuries may include hypoxia and near drowning.
(a) The candidate should have had an appropriate hierarchy of priorities from this point. Textbook lists are inadequate. Actions should have been explained and related to the case. GCS and airway patency should be checked but if a sensory level could be accurately ascertained, the patient is possibly talking and maintaining an airway.
Breathing will be of prime concern. A level at C4-5, perhaps complete, would produce loss of all intercostal and some diaphragmatic function. With his age and history of heavy smoking it is likely that intubation would be necessary. A clinical assessment ·of respiration and breathing pattern should be clearly elucidated, not just listed.
A safe technique for intubation should be detailed if the decision is to proceed (eg. blind nasal, 'rapid sequence' or fibre-optic bronchoscopic with in-line traction).
Blood pressure support: bradycardia and relative hypotension are expected. If organ perfusion is adequate, no action is necessary. An associated head injury will necessitate the use of inoconstrictor to maintain CPP or blood loss (eg. from ruptured spleen) will require volume resuscitation.
The candidate should then cover:
- history (recent and past)
- complete assessment of neurological function survey for other injuries
- investigations: ( 3 view x-ray),
- CT or MRI (why, pros and cons),
- steroids: the NASCIS II study showed motor and sensory improvement with
methylprednisolone 30mglkg bolus and 5.4mglkg infusion over 23hrs. Criticised
widely and not used by all but the evidence of benefit is accumulating.
- surgical Vs medical treatment and early Vs late are undecided issues. Most surgeons would decompress a patient with incomplete lesion and significant canal narrowing
- NG tube - ileus
- IDC - urinary retention leads to bladder problems long term
- Temperature maintenance
- DVT prophylaxis
- Pressure area prevention
The college wants a lot from the answer here.
One should intubate this patient. In the second part of this question, the college hectors those candidates who chickened out of intubation in the first part.
Firstly, one should complete the primary survey;
specific features to look for would be
- sources of bleeding
A FAST scan should be performed, looking for intraabdominal haemorrhage.
After all of this is done, the patient should be intubated with inline stabilisation of the C-spine. Videolaryngoscopy is probably the best way of doing this, given the awkwardness of an immobilised neck. This early, it is still safe to use suxamethonium.
Once ventilation is established, the patient should be taken to the CT scanner and a full CT trauma series should be acquired. Specifically, the extent of the spinal injury should be established. With these findings it will be possible to have a meaningful neurosurgical opinion. An MRI in this setting is probably not going to be meaningful unless it directs the neurosurgical approach. It is of use in settings where bony injury is not apparent, and imaging of the cord itself is needed to determine the level at which decompression might be beneficial.
Once surgical management is agreed upon, one can settle down to managing the routine FASTHUG.
As for the steroids... a Cochrane review of methylprednisone seemed promising - if methylprednisone is started withn 8 hours of the injury, and continued for 24-48 hours- but more recently opinion has shifted away from steroids.
Shah, Rajiv R., and Samuel A. Tisherman. "Spinal cord injury." Imaging the ICU Patient. Springer London, 2014. 377-380.
Batchelor, Peter E., et al. "Meta-Analysis of Pre-Clinical Studies of Early Decompression in Acute Spinal Cord Injury: A Battle of Time and Pressure."PloS one 8.8 (2013): e72659.
Bracken, Michael B. "Steroids for acute spinal cord injury." Cochrane Database Syst Rev 1 (2012).
Hurlbert, R. John, et al. "Pharmacological therapy for acute spinal cord injury." Neurosurgery 72 (2013): 93-105.