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C1/C2 injury

Kenneth Mak kenmaksw at gmail.com
Tue May 31 00:40:44 BST 2011

Thanks for all previous comments.
Yes, I haven't found much references in the literature to rotatory
subluxation at C1/C2 to this mechanism of injury.
Patient was intubated during CPR when she was having PEA. No neuromuscular
blockage was administered.
She is not paralysed and yes, the torticollis is persisting, with the neck
immobilised in place.
I'm grateful for the reminder from Dr McSwain to avoid excessive fluid
loading, given the cerebral oedema.We kept fluid therapy to the minimum
needed to maintain adequate urine output.
We did not arrange an MRI scan earlier, as we didn't have a MR compatible
ventilator available when she presented to the hospital. But I don't think
the torticollis is physiological.
Dr Mattox's comments about the need for ethical considerations are cogent. I
did not present this information earlier - this young lady is a contract
domestic maid from overseas with no family in the country. We're trying to
contact her family to participate in a discussion about treatment and
resuscitation goals. Over the last 72h, she remains neurologically flat,
without sedation or paralsis. Pupillary reflexes are absent. We're hoping to
get in touch with the family before we commence tests for brain stem
function. Unless determined otherwise, we remain committed to supporting her
in the ICU.

Kenneth Mak

On Tue, May 31, 2011 at 7:13 AM, Rob Ojala <Rob.Ojala at cdhb.govt.nz> wrote:

> Question - was the 'tortacollis' you describe persisting AFTER
> neuromuscular blockade was established? - ie was there a mechanical
> reason beyond muscular spasm creating this neck position?
> Two comments-
> 1. Rotatory subluxation following self hanging is quite atypical.
> 2. Physiological rotation in normal individuals at c1/c2 is in the order
> of 80 degrees [can provide ref if desired]
> Ergo is it worth doing an MRI to see if there is ligamentous rupture to
> support a diagnosis of c1-2 instability - because this might all be
> physiological?
> Rob Ojala
> -----Original Message-----
> From: trauma-list-bounces at trauma.org
> [mailto:trauma-list-bounces at trauma.org] On Behalf Of Kenneth Mak
> Sent: Tuesday, 31 May 2011 1:05 a.m.
> To: Trauma-List [TRAUMA.ORG]
> Subject: C1/C2 injury
> Appreciate advice regarding the management of this cervical injury:
> 25 year old female, found hanged and immediately brought down. Attended
> by paramedics and noted to have PEA - CPR commenced and continued into
> hospital ED, ultimately with return of spontaneous rhythm and
> circulation, but with fixed and dilated pupils. Intubated but difficult
> to maintain inline neck immobilisation due to torticollis.
> Post-resuscitation able to maintain haemodynamic status with volume
> loading alone. CT head shows diffuse cerebral oedema, CT cervical spine
> shows rotatory subluxation of C1 on C2. No obvious fractures noted. Some
> scan images enclosed.
> Outlook is obviously poor but assuming she had a better outcome, how
> should such cervical injuries be managed? I gather these injuries are
> seen more commonly in the paediatric population and often in
> non-traumatic settings.
> Is halo fixation still an option or should C1-C2 fixation be considered?
> Kenneth Mak
> Singapore
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Kenneth Mak
Senior Consultant & Head
Department of General Surgery
Khoo Teck Puat Hospital

Clinical Associate Professor,
Yong Loo Lin School of Medicine
National University of Singapore

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