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Consider this Case Study

Bjorn, Pret trauma-list@trauma.org
Fri, 21 Jun 2002 13:14:03 -0400


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Dr. Meade,
 
Mechanism of injury is not a criterion of the NEXUS guidelines; it's an
indication for them.  That is, if the patient has no mechanism for neck
injury, there's no need to rule it out.  
 
Somebody wakes up with a sore neck, but has zero history of recent injury,
you can try a day or two of ibuprofen before worrying about CT scans or
flexion/extension studies.
 
Pret Bjorn, RN, PN
(Pain in the Neck)
Bangor, ME USA

-----Original Message-----
From: John L. Meade [mailto:jmeade@statdoc.com]
Sent: Friday, June 21, 2002 10:36 AM
To: trauma-list@trauma.org
Subject: RE: Consider this Case Study



Perhaps "field criteria" have been published that are different from the ED
criteria for clinical clearance of cervical spines. The published ED
criteria do not mention mechanism of injury as a criterion. There are 5
criteria that must be met to clinically clear: no midline cervical
tenderness, no focal neurologic deficit, normal alertness, no intoxication,
and no painful, distracting injury.

 

 

Hoffman JR. Mower WR. Wolfson AB. Todd KH. Zucker MI. Validity of a set of
clinical criteria to rule out injury to the cervical spine in patients with
blunt trauma. National Emergency X-Radiography Utilization Study Group. [see
comments.] [erratum appears in N Engl J Med 2001 Feb 8;344(6):464.].
[Journal Article. Multicenter Study] New England Journal of Medicine.
343(2):94-9, 2000 Jul 13.

 

 

JM 

  

John L. Meade, MD, FACEP 

Emergency Medicine Specialist

Emerald Healthcare Group, P.A. 

 <http://www.statdoc.com/> http://www.statdoc.com/  

 

When you dream in color, it's a pigment of your imagination.



-----Original Message-----
From: trauma-list-admin@trauma.org [mailto:trauma-list-admin@trauma.org] On
Behalf Of Krin135@aol.com
Sent: Friday, June 21, 2002 08:59
To: trauma-list@trauma.org
Subject: Re: Consider this Case Study

 

In a message dated 05-Jun-02 13:58:26 Central Daylight Time,
dinerman@computron.net writes:




Case in point regarding vascular Doppler in the field:

On my last shift I attended a 34 y/o male bicyclist who, while on his
customary pre-dawn ride,  hit a hard to see gate and fell on his extended
right arm. He was rewarded with a severely angulated, fractured / dislocated
right elbow. (Probably snapped the humeral head off).  He was wearing his
helmet tho.  (Said he bikes for his health!)  

Cleared C-spine according to our protocol, discovered no other notable
injuries during the full exam,(some minor road rash / lacs) splinted the arm
from shoulder to fingertips (no radial pulse was noted before or after
splinting), moved him to the rig, started IV NS for analgesia, administered
4 mg Morphine for pain, obtained vascular Doppler of distal fingertips
indicating circulation present, transported to local ED.  Local ED MD
confirmed Doppler, and diagnosis via x-ray. Local ortho and vascular
specialists were contacted and Pt was transferred from local ED to Houston
(75 miles) for open reduction at a specialist ortho hospital.  



Catching up with the list after a long spell of not being able to read in
detail...

Just out of curiosity, how did you clear this patient's C spine clinically,
since he had a significant distracting injury as well as a significant
mechanism of injury? Any scuff marks on the helmet? IIRC, all of the current
protocols specify that patients with both of those factors (mechanism and
distracting injury) should *not* be cleared in the field.

Got bit on that one a long time ago, with a gal who had a dislocated
shoulder from a 4 wheeler wreck. Turned out that the pain in the shoulder
was masking neck pain, and follow up films were suspicious for a posterior
fracture.

We weren't able to do CT at that hospital that weekend, so had to ship her
off...I suspect that there was no significant sequelae, as she was lost to
follow up, but it did get my pulse to rise for a bit.

ck


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<DIV><FONT color=#800000 face=Arial size=2><SPAN class=370480517-21062002>Dr. 
Meade,</SPAN></FONT></DIV>
<DIV><FONT color=#800000 face=Arial size=2><SPAN 
class=370480517-21062002></SPAN></FONT>&nbsp;</DIV>
<DIV><FONT size=2><FONT color=#800000><FONT face=Arial><SPAN 
class=370480517-21062002>Mechanism of injury is not a criterion of the NEXUS 
guidelines; it's an <EM>indication for them</EM>.&nbsp; That is, if the patient 
has no mechanism for neck injury, there's no need to rule it out</SPAN><SPAN 
class=370480517-21062002>.&nbsp; </SPAN></FONT></FONT></FONT></DIV>
<DIV><FONT size=2><FONT color=#800000><FONT face=Arial><SPAN 
class=370480517-21062002></SPAN></FONT></FONT></FONT>&nbsp;</DIV>
<DIV><FONT size=2><FONT color=#800000><FONT face=Arial><SPAN 
class=370480517-21062002>Somebody wakes up with a sore neck, but has zero 
history of recent injury, you can try a day or two of ibuprofen before worrying 
about CT scans or flexion/extension studies.</SPAN></FONT></FONT></FONT></DIV>
<DIV><FONT size=2><FONT color=#800000><FONT face=Arial><SPAN 
class=370480517-21062002></SPAN></FONT></FONT></FONT>&nbsp;</DIV>
<DIV><FONT color=#800000 face=Arial size=2><SPAN class=370480517-21062002>Pret 
Bjorn, RN, PN</SPAN></FONT></DIV>
<DIV><FONT color=#800000 face=Arial size=2><SPAN class=370480517-21062002>(Pain 
in the Neck)</SPAN></FONT></DIV>
<DIV><FONT color=#800000 face=Arial size=2><SPAN 
class=370480517-21062002>Bangor, ME USA</SPAN></FONT></DIV>
<BLOCKQUOTE style="MARGIN-RIGHT: 0px">
  <DIV align=left class=OutlookMessageHeader dir=ltr><FONT face=Tahoma 
  size=2>-----Original Message-----<BR><B>From:</B> John L. Meade 
  [mailto:jmeade@statdoc.com]<BR><B>Sent:</B> Friday, June 21, 2002 10:36 
  AM<BR><B>To:</B> trauma-list@trauma.org<BR><B>Subject:</B> RE: Consider this 
  Case Study<BR><BR></DIV></FONT>
  <DIV class=Section1>
  <P class=MsoNormal><FONT color=black face=Arial size=3 
  FAMILY="SANSSERIF"><SPAN style="COLOR: black; FONT-SIZE: 12pt">Perhaps &#8220;field 
  criteria&#8221; have been published that are different from the </SPAN></FONT><FONT 
  color=black><SPAN style="COLOR: black">ED</SPAN></FONT><FONT color=black><SPAN 
  style="COLOR: black"> criteria for clinical clearance of cervical spines. The 
  published </SPAN></FONT><FONT color=black><SPAN 
  style="COLOR: black">ED</SPAN></FONT><FONT color=black><SPAN 
  style="COLOR: black"> criteria do not mention mechanism of injury as a 
  criterion. There are 5 criteria that must be met to clinically clear: no 
  midline cervical tenderness, no focal neurologic deficit, normal alertness, no 
  intoxication, and no painful, distracting injury.</SPAN></FONT></P>
  <P class=MsoNormal><FONT color=black face=Arial size=3><SPAN 
  style="COLOR: black; FONT-SIZE: 12pt">&nbsp;</SPAN></FONT></P>
  <P class=MsoNormal><FONT color=black face=Arial size=3><SPAN 
  style="COLOR: black; FONT-SIZE: 12pt">&nbsp;</SPAN></FONT></P>
  <P class=MsoNormal><FONT color=black face=Arial size=3><SPAN 
  style="COLOR: black; FONT-SIZE: 12pt">Hoffman</SPAN></FONT><FONT 
  color=black><SPAN style="COLOR: black"> JR. Mower WR. </SPAN></FONT><FONT 
  color=black><SPAN style="COLOR: black">Wolfson</SPAN></FONT><FONT 
  color=black><SPAN style="COLOR: black"> </SPAN></FONT><FONT color=black><SPAN 
  style="COLOR: black">AB.</SPAN></FONT><FONT color=black><SPAN 
  style="COLOR: black"> </SPAN></FONT><FONT color=black><SPAN 
  style="COLOR: black">Todd</SPAN></FONT><FONT color=black><SPAN 
  style="COLOR: black"> </SPAN></FONT><FONT color=black><SPAN 
  style="COLOR: black">KH</SPAN></FONT><FONT color=black><SPAN 
  style="COLOR: black">. Zucker MI. Validity of a set of clinical criteria to 
  rule out injury to the cervical spine in patients with blunt trauma. National 
  Emergency X-Radiography Utilization Study Group. [see comments.] [erratum 
  appears in N Engl J Med 2001 Feb 8;344(6):464.]. [Journal Article. Multicenter 
  Study] </SPAN></FONT><FONT color=black><SPAN style="COLOR: black">New 
  England</SPAN></FONT><FONT color=black><SPAN style="COLOR: black"> Journal of 
  Medicine. 343(2):94-9, 2000 Jul 13.</SPAN></FONT></P>
  <P class=MsoNormal><FONT color=black face=Arial size=3><SPAN 
  style="COLOR: black; FONT-SIZE: 12pt">&nbsp;</SPAN></FONT></P>
  <P class=MsoNormal><FONT color=black face=Arial size=3><SPAN 
  style="COLOR: black; FONT-SIZE: 12pt">&nbsp;</SPAN></FONT></P>
  <DIV>
  <P class=MsoPlainText><FONT color=black face=Arial size=3><SPAN 
  style="COLOR: black; FONT-FAMILY: Arial; FONT-SIZE: 12pt">JM 
</SPAN></FONT></P>
  <P class=MsoPlainText><FONT color=black face=Arial size=3><SPAN 
  style="COLOR: black; FONT-FAMILY: Arial; FONT-SIZE: 12pt">&nbsp; 
  </SPAN></FONT></P>
  <P class=MsoPlainText><FONT color=black face=Arial size=3><SPAN 
  style="COLOR: black; FONT-FAMILY: Arial; FONT-SIZE: 12pt">John</SPAN></FONT><FONT 
  color=black face=Arial size=3><SPAN 
  style="COLOR: black; FONT-FAMILY: Arial; FONT-SIZE: 12pt"> </SPAN></FONT><FONT 
  color=black face=Arial size=3><SPAN 
  style="COLOR: black; FONT-FAMILY: Arial; FONT-SIZE: 12pt">L.</SPAN></FONT><FONT 
  color=black face=Arial size=3><SPAN 
  style="COLOR: black; FONT-FAMILY: Arial; FONT-SIZE: 12pt"> </SPAN></FONT><FONT 
  color=black face=Arial size=3><SPAN 
  style="COLOR: black; FONT-FAMILY: Arial; FONT-SIZE: 12pt">Meade</SPAN></FONT><FONT 
  color=black face=Arial size=3><SPAN 
  style="COLOR: black; FONT-FAMILY: Arial; FONT-SIZE: 12pt">, 
  </SPAN></FONT><FONT color=black face=Arial size=3><SPAN 
  style="COLOR: black; FONT-FAMILY: Arial; FONT-SIZE: 12pt">MD</SPAN></FONT><FONT 
  color=black face=Arial size=3><SPAN 
  style="COLOR: black; FONT-FAMILY: Arial; FONT-SIZE: 12pt">, FACEP 
  </SPAN></FONT></P>
  <P class=MsoPlainText><I><FONT color=black face=Arial size=3><SPAN 
  style="COLOR: black; FONT-FAMILY: Arial; FONT-SIZE: 12pt; FONT-STYLE: italic">Emergency 
  Medicine Specialist</SPAN></FONT></I></P>
  <P class=MsoPlainText><FONT color=black face=Arial size=3><SPAN 
  style="COLOR: black; FONT-FAMILY: Arial; FONT-SIZE: 12pt">Emerald Healthcare 
  Group, P.A. </SPAN></FONT></P>
  <P class=MsoPlainText><FONT color=black face="Courier New" size=2><SPAN 
  style="COLOR: black; FONT-SIZE: 10pt"><A href=http://www.trauma.org/index.php/community/list/url/http:list.ftech.net/pipermail/trauma-list/2002-June/"http://www.statdoc.com/"><FONT 
  color=black face=Arial size=3><SPAN 
  style="COLOR: black; FONT-FAMILY: Arial; FONT-SIZE: 12pt">http://www.statdoc.com/</SPAN></FONT></A></SPAN></FONT><FONT 
  color=black face=Arial size=3><SPAN 
  style="COLOR: black; FONT-FAMILY: Arial; FONT-SIZE: 12pt">&nbsp; 
  </SPAN></FONT></P>
  <P class=MsoPlainText><FONT color=black face="Courier New" size=2><SPAN 
  style="COLOR: black; FONT-SIZE: 10pt">&nbsp;</SPAN></FONT></P>
  <P class=MsoPlainText><EM><B><I><FONT color=black face="Times New Roman" 
  size=2><SPAN style="COLOR: black; FONT-SIZE: 10pt; FONT-WEIGHT: bold">When you 
  dream in color, it's a pigment of your 
  imagination.</SPAN></FONT></I></B></EM><FONT color=navy><SPAN 
  style="COLOR: navy"><BR><BR></SPAN></FONT></P></DIV>
  <P class=MsoNormal style="MARGIN-LEFT: 0.5in"><FONT color=black face=Tahoma 
  size=2><SPAN 
  style="COLOR: black; FONT-FAMILY: Tahoma; FONT-SIZE: 10pt">-----Original 
  Message-----<BR><B><SPAN style="FONT-WEIGHT: bold">From:</SPAN></B> 
  trauma-list-admin@trauma.org [mailto:trauma-list-admin@trauma.org] <B><SPAN 
  style="FONT-WEIGHT: bold">On Behalf Of </SPAN></B>Krin135@aol.com<BR><B><SPAN 
  style="FONT-WEIGHT: bold">Sent:</SPAN></B> </SPAN></FONT><FONT color=black 
  face=Tahoma size=2><SPAN 
  style="COLOR: black; FONT-FAMILY: Tahoma; FONT-SIZE: 10pt">Friday, June 21, 
  2002</SPAN></FONT><FONT color=black face=Tahoma size=2><SPAN 
  style="COLOR: black; FONT-FAMILY: Tahoma; FONT-SIZE: 10pt"> 
  </SPAN></FONT><FONT color=black face=Tahoma size=2><SPAN 
  style="COLOR: black; FONT-FAMILY: Tahoma; FONT-SIZE: 10pt">08:59</SPAN></FONT><FONT 
  color=black face=Tahoma size=2><SPAN 
  style="COLOR: black; FONT-FAMILY: Tahoma; FONT-SIZE: 10pt"><BR><B><SPAN 
  style="FONT-WEIGHT: bold">To:</SPAN></B> trauma-list@trauma.org<BR><B><SPAN 
  style="FONT-WEIGHT: bold">Subject:</SPAN></B> Re: Consider this Case 
  Study</SPAN></FONT></P>
  <P class=MsoNormal style="MARGIN-LEFT: 0.5in"><FONT color=black face=Arial 
  size=3><SPAN style="COLOR: black; FONT-SIZE: 12pt">&nbsp;</SPAN></FONT></P>
  <P class=MsoNormal style="MARGIN-LEFT: 0.5in"><I><FONT color=black 
  face="Arial Black" size=2><SPAN 
  style="COLOR: black; FONT-FAMILY: 'Arial Black'; FONT-SIZE: 10pt; FONT-STYLE: italic">In 
  a message dated </SPAN></FONT></I><I><FONT color=black face="Arial Black" 
  size=2><SPAN 
  style="COLOR: black; FONT-FAMILY: 'Arial Black'; FONT-SIZE: 10pt; FONT-STYLE: italic">05-Jun-02</SPAN></FONT></I><I><FONT 
  color=black face="Arial Black" size=2><SPAN 
  style="COLOR: black; FONT-FAMILY: 'Arial Black'; FONT-SIZE: 10pt; FONT-STYLE: italic"> 
  </SPAN></FONT></I><I><FONT color=black face="Arial Black" size=2><SPAN 
  style="COLOR: black; FONT-FAMILY: 'Arial Black'; FONT-SIZE: 10pt; FONT-STYLE: italic">13:58:26</SPAN></FONT></I><I><FONT 
  color=black face="Arial Black" size=2><SPAN 
  style="COLOR: black; FONT-FAMILY: 'Arial Black'; FONT-SIZE: 10pt; FONT-STYLE: italic"> 
  Central Daylight Time, dinerman@computron.net 
  writes:<BR><BR></SPAN></FONT></I></P>
  <P class=MsoNormal style="MARGIN-LEFT: 0.5in"><FONT color=black face=Arial 
  size=2><SPAN 
  style="BACKGROUND: white; COLOR: black; FONT-SIZE: 10pt"><BR></SPAN></FONT><FONT 
  color=black face="Comic Sans MS" size=2 FAMILY="SCRIPT"><SPAN 
  style="BACKGROUND: white; COLOR: black; FONT-FAMILY: 'Comic Sans MS'; FONT-SIZE: 10pt">Case 
  in point regarding vascular </SPAN></FONT><FONT color=black 
  face="Comic Sans MS" size=2><SPAN 
  style="BACKGROUND: white; COLOR: black; FONT-FAMILY: 'Comic Sans MS'; FONT-SIZE: 10pt">Doppler</SPAN></FONT><FONT 
  color=black face="Comic Sans MS" size=2><SPAN 
  style="BACKGROUND: white; COLOR: black; FONT-FAMILY: 'Comic Sans MS'; FONT-SIZE: 10pt"> 
  in the field:<BR><BR>On my last shift I attended a 34 y/o male bicyclist who, 
  while on his customary pre-dawn ride,&nbsp; hit a hard to see gate and fell on 
  his extended right arm. He was rewarded with a severely angulated, fractured / 
  dislocated right elbow. (Probably snapped the humeral head off).&nbsp; He was 
  wearing his helmet tho.&nbsp; (Said he bikes for his health!)&nbsp; 
  <BR><BR>Cleared C-spine according to our protocol, discovered no other notable 
  injuries during the full exam,(some minor road rash / lacs) splinted the arm 
  from shoulder to fingertips (no radial pulse was noted before or after 
  splinting), moved him to the rig, started IV NS for analgesia, administered 4 
  mg Morphine for pain, obtained vascular Doppler of distal fingertips 
  indicating circulation present, transported to local ED.&nbsp; Local 
  </SPAN></FONT><FONT color=black face="Comic Sans MS" size=2><SPAN 
  style="BACKGROUND: white; COLOR: black; FONT-FAMILY: 'Comic Sans MS'; FONT-SIZE: 10pt">ED</SPAN></FONT><FONT 
  color=black face="Comic Sans MS" size=2><SPAN 
  style="BACKGROUND: white; COLOR: black; FONT-FAMILY: 'Comic Sans MS'; FONT-SIZE: 10pt"> 
  </SPAN></FONT><FONT color=black face="Comic Sans MS" size=2><SPAN 
  style="BACKGROUND: white; COLOR: black; FONT-FAMILY: 'Comic Sans MS'; FONT-SIZE: 10pt">MD</SPAN></FONT><FONT 
  color=black face="Comic Sans MS" size=2><SPAN 
  style="BACKGROUND: white; COLOR: black; FONT-FAMILY: 'Comic Sans MS'; FONT-SIZE: 10pt"> 
  confirmed </SPAN></FONT><FONT color=black face="Comic Sans MS" size=2><SPAN 
  style="BACKGROUND: white; COLOR: black; FONT-FAMILY: 'Comic Sans MS'; FONT-SIZE: 10pt">Doppler</SPAN></FONT><FONT 
  color=black face="Comic Sans MS" size=2><SPAN 
  style="BACKGROUND: white; COLOR: black; FONT-FAMILY: 'Comic Sans MS'; FONT-SIZE: 10pt">, 
  and diagnosis via x-ray. Local ortho and vascular specialists were contacted 
  and Pt was transferred from local </SPAN></FONT><FONT color=black 
  face="Comic Sans MS" size=2><SPAN 
  style="BACKGROUND: white; COLOR: black; FONT-FAMILY: 'Comic Sans MS'; FONT-SIZE: 10pt">ED</SPAN></FONT><FONT 
  color=black face="Comic Sans MS" size=2><SPAN 
  style="BACKGROUND: white; COLOR: black; FONT-FAMILY: 'Comic Sans MS'; FONT-SIZE: 10pt"> 
  to </SPAN></FONT><FONT color=black face="Comic Sans MS" size=2><SPAN 
  style="BACKGROUND: white; COLOR: black; FONT-FAMILY: 'Comic Sans MS'; FONT-SIZE: 10pt">Houston</SPAN></FONT><FONT 
  color=black face="Comic Sans MS" size=2><SPAN 
  style="BACKGROUND: white; COLOR: black; FONT-FAMILY: 'Comic Sans MS'; FONT-SIZE: 10pt"> 
  (75 miles) for open reduction at a specialist ortho hospital.&nbsp; 
  </SPAN></FONT></P>
  <P class=MsoNormal style="MARGIN-LEFT: 0.5in"><FONT color=black 
  face="Comic Sans MS" size=2><SPAN 
  style="BACKGROUND: white; COLOR: black; FONT-FAMILY: 'Comic Sans MS'; FONT-SIZE: 10pt"><BR></SPAN></FONT><I><FONT 
  color=black face="Arial Black" size=2 FAMILY="SANSSERIF"><SPAN 
  style="BACKGROUND: white; COLOR: black; FONT-FAMILY: 'Arial Black'; FONT-SIZE: 10pt; FONT-STYLE: italic"><BR>Catching 
  up with the list after a long spell of not being able to read in 
  detail...<BR><BR>Just out of curiosity, how did you clear this patient's C 
  spine clinically, since he had a significant distracting injury as well as a 
  significant mechanism of injury? Any scuff marks on the helmet? IIRC, all of 
  the current protocols specify that patients with both of those factors 
  (mechanism and distracting injury) should *not* be cleared in the 
  field.<BR><BR>Got bit on that one a long time ago, with a gal who had a 
  dislocated shoulder from a 4 wheeler wreck. Turned out that the pain in the 
  shoulder was masking neck pain, and follow up films were suspicious for a 
  posterior fracture.<BR><BR>We weren't able to do CT at that hospital that 
  weekend, so had to ship her off...I suspect that there was no significant 
  sequelae, as she was lost to follow up, but it did get my pulse to rise for a 
  bit.<BR><BR>ck</SPAN></FONT></I></P></DIV></BLOCKQUOTE></BODY></HTML>

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