Rosen & Barkin's 5-Minute Emergency Medicine Consult (665 page)

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Authors: Jeffrey J. Schaider,Adam Z. Barkin,Roger M. Barkin,Philip Shayne,Richard E. Wolfe,Stephen R. Hayden,Peter Rosen

Tags: #Medical, #Emergency Medicine

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ETIOLOGY
  • Birth – breech vaginal delivery
  • <8 yr – MVC and falls
  • >8 yr – MVC and sports injuries
DIAGNOSIS
SIGNS AND SYMPTOMS
  • Local cervical spine pain
  • Limited range of motion
  • Neurologic deficit (may be transient)
  • May be masked by altered mental status or distracting injury
  • Abnormal vital signs:
    • Hypotension
    • Bradycardia
    • Hypoventilation or apnea
  • Neck signs:
    • Tender to palpation over cervical spine
    • Limited range of motion
    • Muscle spasm
  • Neurologic signs:
    • Paresthesias or sensory deficit
    • Flaccid tone
    • Loss of rectal tone
    • Paralysis
  • Paralysis:
    • Anterior cord syndrome:
      • Hyperflexion injury
      • Paralysis
      • Loss of pain sensation, preservation of light touch, and proprioception
    • Central cord syndrome:
      • Hyperextension injury
      • Weakness upper greater than lower extremities
      • Burning sensation in hands and fingers
    • Brown-Séquard syndrome:
      • Cord hemisection
      • Ispilateral paralysis
      • Contralateral loss of pain
    • Horner's syndrome:
      • Disruption of sympathetic chain
      • Ipsilateral ptosis, miosis, anhidrosis
      • Also consider carotid dissection
    • Quadriplegia
    • Absent reflexes
  • Preverbal child may be unable to express symptoms and may not cooperate during exam.
ESSENTIAL WORKUP
  • Obtain cervical spine radiographs for:
    • Cervical spine tenderness
    • Altered mental status
    • Neurologic deficit (even if transient)
    • Distracting injury
    • Mechanism of injury
  • Additional imaging studies (CT, MRI) may be indicated if plain radiographs are inconclusive OR clinical exam suggests injury
  • Nexus criteria can be applied safely to children >8 yr of age, but not younger
DIAGNOSIS TESTS & NTERPRETATION
Imaging
  • Cervical spine radiographs:
    • Standard initial views: Anteroposterior, cross-table lateral, and open-mouth odontoid
    • Cross-table lateral identifies ∼80% of fractures, dislocations, and subluxations
    • Addition of AP and odontoid increases sensitivity
    • Need to visualize all 7 cervical vertebrae and C7–T1 junction
    • Space between anterior arch of C1 and anterior aspect of odontoid process:
      • 5 mm or smaller in children and 3 mm in adults
    • Thickening of prevertebral soft tissue:
      • Suggests underlying fracture or ligamentous injury
      • Also occurs with neck flexion, expiration, swallowing
      • Too much variability exists for measurements to be highly sensitive.
      • Soft tissue below the glottis should be approximately twice as thick as above the glottis.
    • Pseudosubluxation of C2:
      • Normal variant
      • A result of ligamentous laxity and often resolves by the age of 8 yr
      • C2 anteriorly displaced on C3
      • Posterior cervical line retains normal relationships.
      • Line drawn between anterior aspect of spinous processes of C1 and C3 should pass within 2 mm of anterior aspect of spinous process of C2.
      • Larger than 2-mm space suggests underlying hangman fracture.
      • Can be applied only at C1–C3
    • Anterior vertebral wedging of C3 and C4:
      • May be mistaken for compression fracture
    • Epiphyseal growth plates may resemble fractures:
      • Posterior arch of C1 fuses by 4 yr of age.
      • Anterior arch of C1 fuses by age 6 yr of age.
      • Base of odontoid fuses with body of C2 by 7 yr of age.
    • Flexion and extension views:
      • Limited use
      • May be useful if suspected occult ligamentous injury
      • Negative cervical spine films
      • No neurologic abnormalities
  • CT scan:
    • If fracture suspected despite negative plain radiographs
    • For further definition of fracture identified on plain radiographs
    • Suspicion of a fracture seen on plain radiographs
    • Inadequate radiographs
  • MRI:
    • Suspected spinal cord injury with or without abnormalities found on plain radiographs or CT
DIFFERENTIAL DIAGNOSIS
  • Cervical muscle strain
  • Torticollis
  • Cervical adenitis
  • Retropharyngeal abscess
  • Meningitis
TREATMENT
PRE HOSPITAL
  • Immobilize all infants and children with potential cervical spine injuries
  • Appropriate size cervical collar
  • Tape, towels, padding in combination with car seat or spine board if formal collar not available
  • Place padding under neck, shoulders, and back, as relatively larger cranium can cause flexion
  • In setting of sports injuries, helmets should be left on
INITIAL STABILIZATION/THERAPY
  • Maintain cervical spine immobilization.
  • Logroll patient.
  • Maintenance of inline cervical spine immobilization if intubation is required.
ED TREATMENT/PROCEDURES
  • Any trauma patient with neurologic deficit consistent with spinal cord injury should have methylprednisolone considered.
  • Neurosurgical consultation:
    • True subluxation
    • Fracture
    • Transient or persistent neurologic deficit
MEDICATION
CONTROVERSIAL
  • Methylprednisolone: Loading dose 30 mg/kg IV over 1 hr; maintenance infusion 5.4 mg/kg/hr over next 23 hr; initiate within 8 hr of injury
  • Can cause immunosuppression and increase risk of infection
  • Recommend discussion with neurosurgery prior to initiation
FOLLOW-UP
DISPOSITION
Admission Criteria
  • Altered mental status
  • Signs/symptoms of spinal cord injury
  • Fracture
  • Obtain appropriate consultation:
    • Neurosurgery
    • Orthopedic spine
Discharge Criteria
  • Completely normal mental status
  • No radiographic abnormalities
  • No transient or persistent neurologic deficit
  • Educate parents:
    • SCIWORA can present with delayed onset of symptoms.
    • Patient should return to hospital if paresthesias, weakness, or paralysis is present.
FOLLOW-UP RECOMMENDATIONS
  • Follow up with orthopedic surgeon or neurosurgeon as directed
  • If concussion suspected, follow-up suggested
  • Children with significant trauma should have psychological follow-up.
PEARLS AND PITFALLS
  • Maintain appropriate immobilization during evaluation.
  • In most cases, plain radiographs can be used as initial screening tool.
  • Be aware of unique features of pediatric cervical spine.
  • Symptoms of SCIWORA can be transient or delayed.
ADDITIONAL READING
  • Bracken MB. Steroids for acute spinal cord injury.
    Cochrane Database Syst Rev.
    2012;1:CD001046. doi:10.1002/14651858.CD001046.pub2.
  • Caviness AC. Evaluation of cervical spine injuries in children and adolescents. UpToDate. Available at
    http://www.uptodate.com/contents/evaluation-of-cervical-spine-injuries-in-children-and-adolescents
    .
  • Mohseni S, Talving P, Branco BC, et al. Effect of age on cervical spine injury in pediatric population: A National Trauma Data Bank review.
    J Pediatr Surg
    . 2011;46(9):1771–1776.
  • Swischuk LE.
    Imaging of the Cervical Spine in Children
    . New York, NY: Springer-Verlag; 2004.
CODES
ICD9
  • 805.00 Closed fracture of cervical vertebra, unspecified level
  • 847.0 Sprain of neck
  • 959.09 Injury of face and neck
ICD10
  • S12.9XXA Fracture of neck, unspecified, initial encounter
  • S13.4XXA Sprain of ligaments of cervical spine, initial encounter
  • S19.9XXA Unspecified injury of neck, initial encounter
SPINE INJURY: COCCYX
Gary Schwartz
BASICS

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