CASE BASED DISCUSSION

DR. M. INSAB AHAMED

MRCEM 1ST Year
A 57 year old man came with the alleged history of self fall from stairs at a lodge in sirumalai around 9.30pm on 10/12/22 and
sustained injury to right supra orbital ridge with loss of consciousness for 30mins
whats your next line of Management ?
A - Patent and maintaining, C-spine immobilized, C-spine tenderness present
B- B/L Air entry Decreased , Percussion dullness in B/L chest , B/L lung sliding absent , Saturation - 95% with
4LO2/min
C- Peripheral pulse - feeble, S1S2+, Chest compression+, pelvic compression+, HR- 78/min, BP - 100/50mmhg
D- GCS -15/15, B/L PERL+, Power Right Upper limb - 3/5, Lower limb - 1/5, Left Upper Limb - 3/5 and left lower
limb - 1/5 , CBG-282mg/dl
E- Afebrile, Right suprorbital suture + , Foley’s catheter+,central line + , PR - No malena , No bleeding
whats your differential diagnosis and investigations required?
INVESTIGATION
ABG
PH - 7.30
PCO2 - 24.2
PO2 - 97
Na- 153
K - 4.40
Cl - 116
LACTATES - 1.2
HCO3 - 11.5
ANION GAP - 25.5
ECG
POCUS
B/L Lung sliding absent
Mild LV systolic dysfunction
No free fluids
IVC collapsed
Bladder - Empty Foley’s in situ
What’s your ED Plan?
ED Plan
• IVF RL 500ml bolus
• Reassess vitals every 30mins
• Pain Management
• MLC
• Pelvic Binder
• X-ray Pelvis with both hips,X-ray thigh AP and L view
History and events
K/C/O - DM/CAD - OLD AWMI, S/P - PTCA

Initially taken to Government hospital on 10/12/22 and suturing done in right supra orbital
region and went to another hospital on 11/12/22 and diagnosed as Spinal shock, C4C5 IVDP,
severe spinal canal stenosis

CT ABDOMEN - NO ABNORMALITIES
CT DORSAL SPINE - Fracture of 1st,4th,5th right ribs and 7th left rib
CT CERVICAL SPINE - No evidence of fracture or dislocation
CT Brain - No ICH or fracture
CT FACIAL BONE - mildly displaced fracture of superolateral wall of right orbit
MRI Spine - c4,c5,c6,c7 Intervertebral disc prolapse,severe spinal canal stenosis and Right
minimal Hemothorax and Left minimal pleural effusion
ECHO - Regional wall motion abnormality present, Mild LV systolic dysfunction present (EF-
46%)
treated with antibiotics,steroids and ionotropes
Reassesed Vitals
• BP - 70/50mmhg
• PR - 72/min
• Spo2 - 97% with 5LO2/min
• GCS - 15/15
Plan ?
ED Plan
• Another fluid bolus of NS 0.9% 500ml was given
• Started on Ionotropes - Noradrenaline
• To reasses vitals every 15mins
Reassessed Vitals
• BP- 70/50mmhg
• PR - 75/min
• SPO2 - 97% with 5LO2/min
• On Noradrenaline - 10ml/hr
• IVF - RL @30ml/hr
• Patient is being shifted to VHC with ionotropes for further care
 On arrival to VHC
• BP- 110/70mmhg
• HR- 98/min
• SPO2 - 99% with 4LO2/min
• CBG - 291mg/dl
• On Norad - 10ml/hr
After Discussing with primary team Antibiotics and steriods were initiated
• Inj.Methylprednislone 500mg was given

Plan :
In view of persistent hypotension ionotopes support has been increased
Reassess vitals every 15mins
Next what’s your choice of ionotropes?
• Dopamine was initiated @ 10mcg/kg/min
Vitals
• BP - 100/60mmhg
• HR- 140/min
• Spo2- 97% with 4LO2/min

• What’s the mistake here?

• What’s your next line of management?
• Dopamine was stopped and vasopressin was initiated
• BP- 100/70mmhg
• PR- 104/min
• Spo2- 99% with 5LO2/min
• Sr.Ketones resulted as 6.6
• Whats your next plan?
• Repeat ABG values with 10LO2/min
• pH - 7.0
• pCO2 - 36.2
• pO2 - 86
• K - 4.63
• Na- 146
• Cl- 116
• Lactate - 2.7
• HCO3 - 10.1
• Anion Gap - 25.3
• Started On Human Actrapid Insulin - 4units/hr
• Differential Diagnosis ? DKA
• Plan - Monitor CBG hourly
• IVF on flow
• On dual ionotropes

• What’s your next line of management?

• Sudden worsening hypoxia, decreased GCS , persistent hypotension
and threatened airway
Vitals
• BP - 60/?
• HR- 140/min
• SPO2- 89% with 10LO2/min
• RR- 30b/min

• What’s your next line of management?

• Intubated with maintaining in line
stabilization
• Drugs used : Inj.Fentanyl 100mcg
Inj. Ketamine 100mg

Post Intubation Vitals

BP- ?
HR-138/min
RR- 16b/min
Spo2 - 100% with Ventilator support
S/E : RS - B/L AE +, No Tension
pneumothorax

Whats your next line of management?

Repeat ABG values with Ventilator
• pH - 7.04
• pCO2 - 32.2
• pO2 - 108
• K - 3.41
• Na - 147
• Cl - 115
• Lactates - 3.2
• HCO3 - 10.2
• Anion Gap - 22.0
• CXR - No obvious abnormalities and pulmonary edema
Vitals :
• BP - ?
• HR- 131/min
• RR- 16b/min
• SpO2 - 96% with ventilator
What’s your next line of management?
• In view of persistent hypotensio 3rd ionotropes was started
Adrenaline infusion started @ 1oml/hr
Repeat POCUS
Moderate LV dysfunction
No B- lines
IVC- full
No free fluids
No PE
sliding sign present
• Suddenly Patient carotid pulse not felt
• CPR initated as per ACLS protocol
Vitals
BP- ?
HR- 82/min
Spo2 - 90%

After 13 cycles of CPR, no ROSC obtained patient declared dead

What’s the cause of Death?

- Spinal Shock
-DKA
-Spinal Canal Stenosis
- IVDP
 Anatomy

Human spine consists of 33 bony vertebrae

7 cervical, 12 thoracic, 5 lumbar, 5 sacral (fused into one) and 4 coccygeal (usually fused
into one
These 26 individual units are separated from one another by flexible intervertebral disks
and connected to form a single functioning unit by a complex network of ligaments
The vertebral column protects the spinal cord, which extends from the midbrain to the level
of the second lumbar vertebra
 SPINAL COLUMN INJURIES

Cervical Spine (C1-C7)

Vulnerable to injury because it is the most exposed, flexible, and mobile portion of
the spinal column
Thoracic spine (T1-T10)

• It is a rigid segment, with its stiffness enhanced by articulation with the rib cage

• Injury to the thoracic spine less common than in other regions

• In case of a thoracic vertebral injury it indicates the patient was subjected to

severe traumatic forces and is at high risk for intrathoracic injuries

• Moreover, the spinal canal in the thoracic region is also narrower than in other
regions

• This increases the risk of cord injury, which is often complete when it occurs
Thoracolumbar junction (T11-L2)

• It is a transitional zone between the highly fixed thoracic and relatively

mobile lumbar spine

• Relative to the thoracic spine, the width of the spinal canal in the
thoracolumbar region is greater

• Therefore, despite a large number of vertebral injuries at the

thoracolumbar junction, most do not have neurologic deficits, or, if
present, they are partial or incomplete
Lower lumbar spine (L3-L5)

• It is more mobile because of the width of the spinal canal in the lumbar region
and the ending of the spinal cord at the L1 level

• Isolated fractures of the lower lumbar spine rarely injure the spinal cord or
result in neurologic injury
Sacrum and Coccyx

• It form the lower portion of the spinal column

• The vertebral foramina of the sacrum together form the sacral canal that
contains the nerve roots of the lumbar, sacral, and coccygeal spinal nerves and
the filum terminale

• The coccyx, which articulates with the sacrum, consists of four vertebrae fused
together

• Sacral fractures that involve the central sacral canal can produce bowel or
bladder dysfunction
 Fracture Stability

• Spinal stability is defined as the ability of the spine to limit patterns of

displacement under physiologic loads so as not to damage or irritate the spinal
cord or nerve roots

• A spine injury is considered unstable if at least two columns of a particular

region are involved
Major Spinal Column Injuries

Jefferson’s - burst fracture of C1

Hangman’s - fracture of the pedicles of C2
Clay shoveller’s - avulsion of the tip of spinous process C7
Chance fracture - Often occurs in the lumbar spine of a car passenger
wearing only a lap-belt for restraint
 SPINAL CORD INJURIES
Two types of injury

1.Primary injury - mechanical forces that directly traumatize the spinal

cord and vasculature

2.Secondary injury - vascular and chemical processes that is caused by

Primary Injury
CLASSIFICATION OF SPINAL CORD SYDROMES

1.COMPLETE SPINAL CORD SYNDROME

2.INCOMPLETE SPINAL CORD SYNDROME

COMPLETE SPINAL CORD SYNDROME

• Most common cause trauma

• Total loss of sensory , autonomic and voluntary motor innervation distal to

the level of injury

• Presence of rectal reflex or slight voluntary movement R/O complete lesion

• SPINAL SHOCK is loss of muscle tone and reflexes

 INCOMPLETE SPINAL CORD SYNDROME

Mechanisms of Injury
• Hyper extension
• Cervical spinal stenosis

Clinical presentation

• Quadriparesis

• Some loss of pain and temperature

sensation

•Upper extremities > lower extremities

 Brown – Sequard syndrome

Mechanisms

• Transverse hemisection of the spinal cord

• Unilateral cord compression

Clinical presentation

• Ipsilateral loss of motor function

(corticospinal) / vibration, proprioception

• Contralateral loss of pain and temperature

(lateral spinothalamic tract)
 Anterior cord syndrome

Mechanisms
• Direct anterior cord compression
• Flexion of cervical spine

Clinical presentation

• Complete paralysis below the lesion with loss of pain

and temperature sensation
• Preservation of proprioception and vibratory function
 CAUDA EQUINA SYNDROME

• Not a true spinal cord syndrome

• The cauda equina is composed entirely of lumbar, sacral, and

coccygeal nerve roots

• Injuries to this region produce peripheral nerve injuries

Out-of-Hospital Care
• Spinal Column Stabilization

• With the use of a backboard, rigid cervical collar, and supportive blocks on
both sides of the head with a concerning mechanism of injury

• Also, cervical collars can hide other injuries, such as lacerations and
hematomas, and have even been found to result in worsening vertebral
distraction injuries
 Evaluation in ED (Primary Survey)
• The ABCDEs––airway, breathing, circulation, disability, and exposure––take
utmost priority

• Generally, the diagnosis and treatment of most spine injuries can be

deferred to address other life-threatening injuries such as hemorrhage or
traumatic brain injury, as long as spinal protection is maintained

• In disability portion of the primary survey, clinicians should quickly

perform basic neurologic assessment
 Evaluation in ED ( Secondry Survey )

In patients with suspected spine injury, the entire spinal column and
paravertebral musculature should be examined for deformity and palpated in a
search for areas of focal tenderness
Motor Grading System

Grade Movement
0 No active contraction
1 Tracevisible or palpable contraction
2 Movement with gravity eliminated
3 Movement against gravity
4 Movement against gravity plus resistance
5 Normal power
Level of Lesion Resulting Level of Loss of
Motor

_x0002_ Elbow flexion

C5
C7 Elbow extension

C8 Finger flexion
T1 Finger abduction
L2 Hip flexion
L3 Knee extension
L4 Ankle dorsiflexion
SI Ankle plantar flexion
Level of Lesion Resulting Level of Loss of
Sensation
C2 Occiput

C3 Thyroid cartilage
C4 Suprasternal notch
C5 below clavicle
C6 thumb
C7 index finger
C8 small finger
T4 Nipple line

T10 Umblicus
L1 Femoral Pulse
L2-L3 Medial aspect of thigh
L4 Knee
L5 Lateral aspect of calf
S1 Lateral Aspect of foot
S2–S4 Perianal region
 Spinal examination

• Log roll the patient

• The person controlling the head and neck directs movement

• Carefully examine for bony tenderness, step deformity, widening of

interspinous gaps, and prominence of spinous processes
• To test for saddle anesthesia which is a sensory deficit in the region of the
buttocks, perineum, and inner aspect of the thighs

• To test the bulbocavernosus reflex squeeze the penis to determine whether the
anal sphincter simultaneously contracts

• Test the cremasteric reflex by stroking the medial thigh with a blunt instrument
if the scrotum rises, some spinal cord integrity exists
How do you remove immobilization device ?
What’s the initial imaging modality?
• CT describe bony abnormalities and the extent of spinal canal
encroachment

• CT are useful for patients in whom there is clinical suspicion of injury

(persistent pain, positive neurology)

• When to do MRI?
 Indications for MRI

• Symptomatic patients with a negative CT findings

• Persistent neurologic deficit

• Positive CT in order to evaluate the spinal cord

Management
 Initial Management in confirmed or suspected TSI

• Once a fracture has been diagnosed, the patient should be maintained with
spinal motion restriction during all treatments

• Patients with cervical TSIs often have life-threatening issues that are a direct
consequence of their spine injury
 AIRWAY

Patients with cervical TSI can be at exceptionally high risk of airway compromise due to several
factors like
• Aspiration
• Intoxicated patient
• Hematoma/local bleeding

Patients with cervical TSI who require intubation should be intubated by

using an in-line stabilization technique

Cervical collar should be removed with in-line stabilization carefully maintained

Indications for intubation
Absolute Indications
Complete SCI above C5 level
Respiratory distress
Hypoxemia despite adequate
attempts at oxygenation
Severe respiratory acidosis
Dyspnea
Relative Indications
Complaint of shortness of breath
Paradoxical abdominal work of
breathing
Functionally decreased VC:
Inability to hold breath for 12
seconds or inability to count to 20
on 1 breath
 Breathing

 Patients with cervical TSI are at high risk of inadequate oxygenation and ventilation

 Provide Oxygen support to maintain spo >92%

 Hypoxemia can cause severe bradycardia in patients with high cervical TSIs due to unopposed vagal
stimulation

 Non-invasive methods of ventilation should be used with caution it migh lead to an increased risk of
aspiration
 Circulation

What’s the difference between Neurogenic

shock and Spinal Shock?
 NEUROGENIC SHOCK
• Secondary to loss of sympathetic outflow (sympathetic chain originates from T1
to L2)
• Patients lose their vascular tone and become hypotensive resulting in end organ
hypoperfusion
Signs and symptoms
• Hypotension
• Bradycardia
• Flaccid paralysis
• Priapism
• Preserved anocutaneous and bulbocavernosus reflexes
 Spinal shock
Signs and symptoms

• Hypotension
• Bradycardia
• Flaccid paralysis
• Priapism
• It may last hours, days, or months, and can recover
• Anocutaneous and bulbocavernosus reflexes are the first to return
Anocutaneous = scratch perianal skin and look for anal contraction (‘anal wink’) (S4, S5 roots)
• First line treatment of hypotension is fluid resuscitation to ensure euvolemia
(cautious to avoid fluid overload)

• Second line therapy includes vasopressors and/or inotropes

Drugs
Norepinephrine (Dose 2-20mcg/min)
Phenylephrine (Dose 10–200 micrograms/min)
*This is best used in patients with lesions below T6 in whom bradycardia is less of
a concern
Dopamine ( Dose 10-20mcg/kg/min)
Epinephrine ( Dose 2–10 micrograms/min)

To maintain mean arterial blood pressure (MAP) at 85-90 mmHg for the first 7
days following acute traumatic spinal cord injury to improve spinal cord perfusion
Other considerations
• Insert a urinary catheter to monitor urine output and prevent bladder
distension
• If there is no craniofacial injury, an NG tube to be placed
• Adopt a high index of suspicion for thoracic/abdominal injury
• Consider the need for eFAST
 Definitive treatment
• The mainstay of treatment for TSIs is decompression of the spinal cord to
minimize additional injury from cord compression by surgical stabilization of
unstable ligamentous and bony injury
 SPECIAL CONSIDERATIONS -
CORTICOSTEROIDS
The National Acute Spinal Cord Injury Study II High-Dose Methylprednisolone
Protocol
Indications:
Blunt trauma
Neurologic deficit
Treatment must be started with in 8 h of injury
Treatment
• Methylprednisolone,30 milligrams/kgIV bolusover15 min
• The option to start corticosteroids should only be made in conjunction with the
surgeon who will ultimately be caring for the patient and not given routinely.
Corticosteroids are contraindicated in patients with any type of penetrating
spinal injuries
Thank YOU!