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Sciwora Sciwora A 14yo male presents to your ED after he dove into A 14yo male presents to your ED after he dove into a pool and felt shock going down his neck and back, a pool and felt shock going down his neck and back, but he was not knocked out. His friends helped him but he was not knocked out. His friends helped him out of the pool and brought him to the ED. He states out of the pool and brought him to the ED. He states all his symptoms are gone now. On exam you note all his symptoms are gone now. On exam you note some neck tenderness. His X-ray and CT neck are some neck tenderness. His X-ray and CT neck are negative. Your next best step is… negative. Your next best step is… a. Home in soft collar FU with PCP a. Home in soft collar FU with PCP b. Hard C-collar transfer to institution with MRI b. Hard C-collar transfer to institution with MRI c. Admit to neurosurgery with C collar in place c. Admit to neurosurgery with C collar in place d. Admit to trauma surgery with C collar in place d. Admit to trauma surgery with C collar in place e. Discharge home, no need for follow up e. Discharge home, no need for follow up SCIWORA SCIWORA • ______ % of children with SCIWORA have • ______50 % of children with SCIWORA have delayed onset of paralysis, sometimes up to 4 delayed onset of paralysis, sometimes up to 4 days days • Many of these children have paresthesias, • Many of these children have paresthesias, numbness, or weakness at the time or shortly numbness, or weakness at the time or shortly after the injury after the injury • The most important factor in prognosis is • The most important factor in prognosis is ______________________ ______________________initial neurologic status 1 SCIWORA Which of the following is NOT an expected • In the NEXUS study which included 34,000 finding on MRI of patients with SCIWORA ? patients of which 3,000 were children, all SCIWORA (27 total) occurred in adults a. Central disc herniation • Although still more common in kids b. Cord hemorrhage • THE POINT: c. Spinal stenosis • Anyone with initial neuro complaints regardless of a normal X-ray and a normal CT is a d. Cord edema SCIWORA until proven otherwise by an MRI e. Cord contusion (or seen by a neurosurgeon if no MRI) Which of the following is NOT an expected finding on MRI of patients with SCIWORA ? SCIWORA in the Age of MRI • Hemorrhagic changes within the spinal cord caused by MVC were accompanied by permanent a. Central disc herniation complete neuro deficits b. Cord hemorrhage • Trauma patients with initial transient neurological c. Spinal stenosis deficits whose MRI show no cord abnormality have full recovery d. Cord edema • In NEXUS the most common findings on MRI of e. Cord contusion patients with SCIWORA were: central disc herniation, spinal stenosis, cord edema, cord contusion 2 You are taking care of a multiple trauma You are taking care of a multiple trauma patient. After taking care of airway, breathing patient. After taking care of airway, breathing and IV access with volume resuscitation your and IV access with volume resuscitation your next best step is… next best step is… a. To undress the patient a. To undress the patient b. To assess for C-spine trauma b. To assess for C-spine trauma c. To assess Glascow coma score c. To assess Glascow coma score d. To assess pelvic injury d. To assess pelvic injury e. To assess the need for splints e. To assess the need for splints + F (Fast exam) if abdominal trauma Primary Survey: ABCs 1. Airway and C-spine control 2. Breathing – Ventilation (rate and character) 3. Circulation (with hemorrhage control) • pulse, blood pressure, peripheral perfusion, pulse oximeter • MedicAlert® bracelets or necklaces 4. Disability – brief neurologic exam – Glasgow Coma Scale 5. Exposure/ Environment – completely undress the patient but prevent hypothermia 3 A 24yo male involved in rollover MVA where he was thrown out of his vehicle. He has no medical problems. VS: BP 100/70, P 110 , R 18, T37. His pelvis X-ray is shown. Negative FAST exam . Two large bore IV’s have been started. Which of the following is the next best step? a. Transfer to the OR with trauma surgeon b. Pelvic internal fixation c. Advanced airway management d. To radiology for angiography e. To the ICU for pelvic external fixation A 24yo male involved in rollover MVA where he Things that differ, but seem the same was thrown out of his vehicle. He has no medical problems. VS: BP 100/70, P 110 , R 18, T37. His • A 28yo male in an MVA thrown from the vehicle pelvis X-ray is shown. Negative FAST exam . Two with hypotension and tachycardia with neg CXR large bore IV’s have been started. Which of the but obvious pelvic fractures and a +ve FAST following is the next best step? exam (gross blood +ve DPL) goes to the OR a. Transfer to the OR with trauma surgeon b. Pelvic internal fixation • A 28 yo in an MVA thrown from the vehicle with hypotension and tachycardia with neg CXR but c. Advanced airway management obvious pelvic fractures and a neg –ve FAST exam d. To radiology for angiography for embolization or lavage (or < 100,000 rbc/cc on DPL) , pelvic e. To the ICU for pelvic external fixation angiography is the next best step because that combination is due to hemorrhage from pelvic # that may be amenable to embolization 4 5-STEP METHOD OF QUICK AND SIMPLE Trauma in elderly KEYCEPTS PELVIC X-RAY INTERPRETATION • Nothing good about the ‘golden age’ – everything 1. Look quickly to get a feel for symmetry. goes to crap: heart, brain, lungs, kidneys etc… 2. Look at the “circles," the big circle being the • The leading cause of injuries ______ pelvic inlet, the little circles being the obturator • VS may be deceptive foramina. • Increased morbidity w BP < ____ or pulse > ____ 3. Look at the sacroiliac jts. • C-spine have arthritis and spinal stenosis so 4. Look at the pubis potential for further injury during intubation is symphysis. increased 5. Look at the acetabula . • _______ cord injury is increased – this is Hemorrhage is a major cause of death, __________ injury 2 to 6 liters of blood may accumulate in the retroperitoneal space • Delayed presentation of SDH – more space in the brain for crap Trauma in elderly KEYCEPTS Trauma in elderly KEYCEPTS • Nothing good about the ‘golden age’ – everything • With multiple rib fractures – ADMIT them goes to crap: heart, brain, lungs, kidneys etc… • The leading cause of injuries ______falls • Pre-existing lung dz more common • VS may be deceptive • Require pain control • Increased morbidity w BP < ____110 or pulse > ____90 • C-spine have arthritis and spinal stenosis so • Alertness may be an issue potential for further injury during intubation is • May get pneumonia increased • _______Central cord injury is increased – this is • Think about incentive spirometer extension__________ injury • Delayed presentation of SDH – more space in the brain for crap 5 Trauma in Pregnancy KEYCEPTS Trauma in Pregnancy KEYCEPTS • Leading cause of non-obstetric related death • Most common cause of fetal death _______ • Most common cause is MVC >50% (abruption is common cause of maternal death) • Then violence • Other causes of fetal death: maternal shock/death • Then falls • Uterus out of pelvis at__________ • Penetrating trauma in pregnancy • Indications of perimortem C-section • Maternal mortality is LOW • ______________________ + ___________ • Fetal mortality is HIGH • Fetal viability: _______ wks, ____ grams • Placental abruption most commonly • Hypotension on gurney, next best concealed step_________ Trauma in Pregnancy KEYCEPTS Trauma in Pregnancy KEYCEPTS • Fetal monitoring • Most common cause of fetal death _______abruptio >50% (abruption is common cause of maternal death) • Frequent uterine activity is more predictive of abruption than US • Other causes of fetal death: maternal • Indicated for all blunt trauma > 20 wks shock/death gestation • Uterus out of pelvis at__________12 wks • > 8 contractions/hr x 4 hrs – risk of • Indications of perimortem C-section abruption • ______________________Uterus above umbilicus + ___________FHT present • 3 – 7 contractions/hr x 4hrs – extend • Fetal viability: _______24 – 26 wks, ____500 grams monitor for 24 hrs • Hypotension on gurney, next best • < 3 contractions/hr x 4hrs – discharge step_________L lat decub home 6 Kleihaur-BetkeTest – result next day • Detects the presence and quantifies the volume of Cushing Reflex – Increased ICP fetal RBC in the maternal circulation • It is an INSENSITIVE test requiring a minimum • Bradycardia of 5cc of fetal hemorrhage for detection • Hypertension • (Since as little as 0.01 – 0.03cc of fetal blood may result in maternal Rh sensitization the KBT is not useful in most • Respiratory irregularity pregnant patients) • All Rh-ve pregnant patients should be given Rh- immune globulin after significant abdominal Seen in ___30 % of patients with rapid ICP rise trauma Late sign of increased ICP Caveat • 50 mmgm in first 12 wks – 300 mmgm > 12wks Sign of impending brain herniation Preventing secondary insult in moderate TBI Preventing secondary insult in moderate TBI • Intubate at GCS of ___ • Intubate at GCS of ___ • Ventilate to maintain _______ • Ventilate to maintain _______ • Prevent hypotension/anemia • Prevent hypotension/anemia • Elevate head of bed 30% (if you can???) • Elevate head of bed 30% (if you can???) • Seizure prophylaxis - phenytoin • Seizure prophylaxis - phenytoin • Reverse anticoagulants • Reverse anticoagulants • Mannitol/brief hyperventilation for • Mannitol/brief hyperventilation for herniation herniation • NS consult early • NS consult
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