Mock28CC Trauma C spine

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Stem: Polytrauma, young girl on her bicycle and involved in an RTA. Possible neck injury and fracture

How will you assess the patient?

Spoiler

According to ATLS protocol.

What is the general principle of ATLS?

Spoiler

X control bleeding
Airway with cervical spine stabilization
Breathing
Circulation
Disability
Exposure

Elaborate the breathing assessment of this patient
Look (evidence of respiratory distress)
Listen (signs of partial airway obstruction or compromise)
Feel (air or fluid)
Respiratory rate

What will be the breathing problem in this patient and what is its effect on the lung?

Spoiler

This patient may have shallow breathing because of the possibility of affection of the phrenic nerve.

Its effect on the lung is

Spoiler

Decrease in alveolar ventilation
Alveolar collapse
Lung atelectasis
Respiratory acidosis
Why does this patient have respiratory depression?
Affection of phrenic nerve
Intercostal muscles paralysis
CO₂ retention
Brain stem injury
What investigation will you next order?
CT
MRI
Given the following MRI, what is the pathology?

MRI sagittal view showing C5 fracture with retropulsion of the spinal cord

Here's the extracted text, continuing from the previous section:

What is significance of this fracture?

C5 nerve root injury → phrenic nerve affection → weakness of diaphragm → reduced breathing effort → accumulation of CO₂ and alveolar collapse → respiratory acidosis

How will you assess the respiratory function of this patient?

ABG

Given the following ABG, interpret?

↓ PH, ↑ PCO2, normal bicarbonate and hypoxia.
Uncompensated respiratory acidosis

What type of respiratory failure?

Type 2

How to manage respiratory failure?

With BiPAP (bi-level positive airways pressure) aka non-invasive ventilation (NIV)

You may be given ABG showing partially compensated respiratory alkalosis with hypercapnia. What will you do in the ER to improve that?

Good ventilation and high-flow oxygen

The decision is made to do fixation by neurosurgery, what is one thing you will do before surgery?
Triple immobilization
Consent for the surgery
Why this patient has lower limb weakness?

Because the patient has spinal cord injury

What are incomplete spinal cord injuries? / What spinal cord syndromes do you know?
Central cord syndrome Anterior cord syndrome Brown-Séquard syndrome Posterior cord syndrome
Spinal cord compression and central cord oedema with selective destruction of lateral corticospinal tract Injury to anterior spinal cord caused by:
• Direct osseous compression of the anterior spinal cord
• Anterior spinal artery injury Caused by complete cord hemitransection Very rare
Loss
• Motor deficit worse in UE than LE (some preserved motor function)
Preserved
• Sacral sparing Loss
• LCT
  o motor function
• LST
  o pain
  o temperature
Preserved
• DC
• proprioception
• vibratory sense Ipsilateral deficit
• LCT
  o motor function
• DC
  o proprioception
  o vibratory sense
Contralateral deficit
• LST
  o pain
  o temperature
  o spinothalamic tracts cross at spinal cord level (classically 2 levels below) Loss
• proprioception
Preserved
• motor, pain, and light touch

What is the first line of management of this patient?

Dexamethasone (in any fracture spine we're afraid from oedema)

What will be the consequences of affected breathing in this patient?

Shallow breathing leads to alveolar hypoventilation and alveolar collapse and lung atelectasis.

How to manage the respiratory condition in this patient, given that he is already on 100% oxygen?
Call for help (anaesthesia and ITU and my consultant)
Transfer patient to ITU
Intubation by anaesthesia
What will you do for this patient after discharge?
Rehabilitation
Physiotherapy
Spirometry
TEDS
Neck brace