What’s Your Diagnosis? Emergency Department Management of Cervical Spine Injuries
September 13, 2021
Posted by Andy Jagoda MD in: What's Your Diagnosis , trackback
Welcome to this month’s What’s Your Diagnosis Challenge!
But before we begin, check to see if you got last month’s case on High-Altitude Illness: Updates in Prevention, Identification, and Treatment right.
Case Presentation: Emergency Department Management of Cervical Spine Injuries
EMS calls to alert you that they have 24-year-old man with head trauma, and they are 15 minutes out. EMS says the man was found down on the street. He has head trauma and a GCS score of 7, but his vital signs are normal. You anticipate that this patient will need intubation. The EMS crew asks whether they should intubate in the field and whether he requires spinal immobilization…
You asked whether the patient was breathing spontaneously or whether he was showing signs of airway obstruction such as stridor, hoarseness, or muffled voice. EMS responded that the patient was breathing spontaneously and not showing any of these signs, so you recommended that the paramedics provide spinal motion restriction without definitive airway management.
Upon his arrival, you decided the patient required intubation, and you anticipated challenges in terms of minimizing spinal manipulation. You identified teammates who would be responsible for intubation and maintaining inline immobilization. You verified the availability of 2 working suction catheters, bag-valve mask, and monitors with oxygen saturation and end-tidal capnography.
You decided to use a video laryngoscope with a standard geometry Macintosh blade and bougie, but made sure to have a hyperangulated blade, laryngeal mask airway, and surgical airway supplies available. You reviewed with the team your plan for the first, second, and third attempts. You pretreated the patient with IV fentanyl because you were concerned for concomitant head injury. You chose etomidate and rocuronium, based on your patient’s hemodynamic status and your concern for head injury. You preoxygenated him with a nonrebreather mask, avoiding hyperventilation.
Once medications were pushed and the patient was sedated and paralyzed, you had your colleague remove the cervical collar and hold the c-spine throughout the intubation. You were able to get a grade 2 view of the cords using direct laryngoscopy and passed the bougie with no difficulty. Your patient did not desaturate. After intubation, you rushed him to CT, where you confirmed a type 2 odontoid fracture and intraparenchymal hemorrhage.
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