Clearing a Cervical Spine clinically (Mnemonic)

1st step is to look for high risk factors: PAD65

Paresthesias in Extremities, Age more than 65, Dangerous mechanism of injury (high speed, axial load, 1metre or 5 stairs, bicycle, recreational vehicle)

If any of these, get an imaging
If none of these, go to step 2

2nd Step is to look for Low risk factors: PARTS

Delayed onset of neck PAIN,
Ambulatory at any time
Simple Rear End Collision
No Midline Spinal Tenderness, or
Sitting in the ED

If any of these present, no Imaging, go to step 3

Lateral movement of neck 45 degrees

If movement possible, remove the collar

PHYSICAL EXAMINATION VIDEOS: Part 3

Shoulder Examination

Wrist and Hand Examination

 

(Source: Youtube, Credit: MedRevise)

Hip Examination

Knee Examination

Foot and Ankle Examination:

Spine Examination:

All these videos are from Youtube. Majority of them from GeekyMedics. We have just tried to put them together here. These videos are for educational purposes only.

Trauma Assessment Pearls

It may sound as a repetition, but considering the importance of the protocol, for your routine ED Practice and also for the CEM Exams, I wanted to revisit this topic.  View this post, along with my earlier post on Approach to Traumatic Emergencies

Assessment of any trauma victim as we know begins with  alerting the trauma team, donning the 3Gs (gowns, gloves, and goggles) and ABCD & E

Airway & Cervical Spine Immobilization:

• Manually immobilize the spine, and ask the patient his name and how he is?
• Then Look in to the mouth and then at the Chest rise, Listen and Feel
• Attach Nasal Oxygen
• Apply collar

Breathing:

• Inspect the neck, Palpate the neck for crepitus and tracheal positioning
• Ask for O2 Saturation monitor
• Inspect the chest for obvious signs, pattern of breathing
• Palpate for crepitus and blood below, and chest rise
• Percuss the chest and axilla
• Auscultate the chest and axilla
• CXR & Pelvic X ray

Circulation:

• Inspect the abdomen and pelvis for obvious signs
• Inspect and palpate the limbs
• Pulse check
• Ask for BP and 2 Large bore IV lines in the antecubital fossa, collect labs for grouping and matching, FBC, U & Es, Amylase, Normal Saline to keep patency
• Attach to monitor
• Palpate the abdomen and pelvis
• Ask for Fast Scan

Disability:

• Ask the patient how he is now?
• Move the fingers and toes (GCS)
• Look at pupils
• Get Sugar Level (Fingerstick)
• If neurologically unstable  or as per NICE guidelines request for CT to be arranged and neursurgeon to be informed

Exposure:

• Expose the patient
• Ask for temperature
• Cover with blankets

After all these conclude by requesting to arrange for log roll and a rectal examination. Before sending for a CT, EKG, ABG, Foley and NG tube.

If you notice, in every step there was some intervention done, (One of the examinee appearing for Part C said to me yesterday, that all steps have one wire/tube to be attached, except C where there are 3:

A     Oxygen

B      Pulse Ox

C     BP, Monitor, IV Access

D     Fingerstick

E     Temperature Probe

A great way to remember the stuff. Thanks to him for the valuable trick)

Succinyl Choline (Suxamethonium)

A great drug of choice for paralysis in RSI, but carries it's own list of side-effects and C/I.

Dose: 1.5 mg/kg IV

Side Efects (BAHAMAS)

Bronchospasm
Anaphylaxis
Hyperkalemia
Arrythmias (Brady and Tachy)
Malignant Hyperthermia
Apnea (especially in inadequate pseudo-cholinesterase)
Secretions (Salivation)

Contraindications (CNBC Eye)

Crush Injuries
Neurological: Spinal Cord Injury, Myotonic dystrophy
Burns
Chronic Renal Failure
Eye (Penetrating injury of the eye)

(To know more about Anesthesiology Visit www.gasexchange.com)

Case of Paraplegia

A 30 year old male is brought in by paramedics with history of injury at rugby field. The patient describes the injury as forced forward flexion of body by someone dodging from behind and he fell to the ground, which was followed by some players falling on his back. After which he complained of no sensations or possible movements in his both lower limbs.

He lies on bed, and a primary survey indicates preserved A, B, and Cs. In examination of debility, we assess the sensory dermatomal distribution from the abdomen downwards, T10 at umbilicus, T12 at pubis, L1 at Inguinal ligament preserved. No sensation below this level (to dull and pin prick), no motor functions, loss of muscle tone, No DTRs. No sensations at scrotal skin, but tenderness on pressing the testicles. Log roll done to reveal tenderness and step deformity at L1, and loss of rectal tone.

(Picture courtesy: Netter's Atlas)

An X ray of the LS Spine is done and is displayed below:

The case demonstrates dermatomal approach to delineate the site of vertebral injury, and emphasizes on learning the dermatomal distribution of both the upper and lower limbs to be used in traumatic spinal injuries.

Approach to Traumatic Emergencies: ATLS

Here are a group of videos uploaded by Oxford Medical Videos helping us getting a proper understanding of the ideal ATLS approach to trauma cases.

Initial Assessment Normal

Initial Assessment Multi System Injury

Initial Assessment Multi System Injury Continued

Assessment in Pelvic Fracture

Another Nice and Simple Video by Univ of Miami discussing the ABC Approach in Trauma Care

The ABC's of Trauma

BTS Guidelines for Management of Pneumothorax

Full Article: BMJ

(Source: http://www.brit-thoracic.org.uk/Portals/0/Guidelines/PleuralDiseaseGuidelines/Pleural%20Guideline%202010/Pleural%20disease%202010%20pneumothorax.pdf)

Cervical Spine Injury CCS Rule

MCEM Part B and C frequently tests you on this:

When do you do an imaging for cervical spine injury (High Risk Patients)

1  Age > 65
2  High Risk Mechanism of Injury:
    a  Fall from 3 ft or 5 stairs,
    b  High Speed collision > 100 kmph,
    c  Rollover accident, and
    d  Ejection injury
3  Paresthesia in upper limbs
4  Altered level of conciousness (Drug/alcohol abuse)

Low risk Patients

1  Simple rear end collision
2  Delayed onset of pain
3  Ambulatory at any time post event
4  Sitting in the ED
5  No spinal midline tenderness

If any of these present, ask patient to move his neck in 45 degrees to left or right, if that is possible then NO Imaging.

CT Scanning in Head Injury (NICE Guidelines)

CT scanning to be performed in head injury and reports available in 1 hour if any of these is present:

Mnemonic: Very Good Friends Should Drive AlcohoLiCs

V        more than 1 episode of Vomiting
G        GCS less than 13 on ED presentation
           GCS less than 15 at two hours from injury
F         Fractures (observed or expected: Open/Depressed/Base of Skull)
S         Post traumatic Seizures
D        Focal Neurological Deficits
ALC   Any Amnesia/LOC/Coagulopathy (abnormal coagulation/or on Aspirin/Clopigrel)

(Compiled by Dr Sajjad Pathan)

NEXUS Criteria for C-Spine Injury Mnemonic

NEXUS Criteria For Cervical Injury:

N    Neuro Deficit
E     EtOH/Intoxication
X    eXtreme distracting Injury
U    Unable to provide history (Altered LOC)
S    Spinal tenderness (midline)

Courtesy: Academic Life in EM Blog