A 20-year-old hockey player is brought to the emergency department 30 minutes after falling headfirst into the hockey rink boards. He did not lose consciousness during the impact but was unable to move his arms and legs afterward. The patient was placed in a rigid cervical collar and transported to the hospital on a backboard; 2 large-bore intravenous catheters were inserted en route. On arrival, blood pressure is 128/78 mm Hg, pulse is 102/min, and respirations are 14/min. The patient is alert and appears anxious. Cardiopulmonary examination is normal. Neurologic examination shows intact cranial nerves. Pinprick and temperature sensation are absent below the level of the clavicles; vibratory sense is intact. The patient is still unable to move his extremities. CT scan of the cervical spine reveals a burst fracture of C5 with impingement of posteriorly displaced fragments on the spinal cord. Neurosurgery is consulted. Which of the following is the best next step in management of this patient?

Question

A 20-year-old hockey player is brought to the emergency department 30 minutes after falling headfirst into the hockey rink boards.  He did not lose consciousness during the impact but was unable to move his arms and legs afterward.  The patient was placed in a rigid cervical collar and transported to the hospital on a backboard; 2 large-bore intravenous catheters were inserted en route.  On arrival, blood pressure is 128/78 mm Hg, pulse is 102/min, and respirations are 14/min.  The patient is alert and appears anxious.  Cardiopulmonary examination is normal.  Neurologic examination shows intact cranial nerves.  Pinprick and temperature sensation are absent below the level of the clavicles; vibratory sense is intact.  The patient is still unable to move his extremities.  CT scan of the cervical spine reveals a burst fracture of C5 with impingement of posteriorly displaced fragments on the spinal cord.  Neurosurgery is consulted.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

This patient who fell headfirst into the hockey rink boards now has findings (eg, altered sensation, quadriplegia) consistent with cervical spinal cord trauma. As for any trauma patient, his evaluation should begin with a primary survey. Because he is alert with normal respirations, he does not need further airway protection (eg, orotracheal intubation) or mechanical ventilation (Choice E). He is hemodynamically stable and has good intravenous (IV) access (ie, 2 large-bore peripheral IV catheters) for resuscitation. However, gross motor examination shows quadriplegia; therefore, a detailed neurologic examination is performed. primary survey Neurologic examination shows absent pinprick (ie, pain) and temperature sensation (ie, spinothalamic tract), as well as bilateral paralysis (ie, lateral corticospinal tract); vibratory sensation (ie, dorsal columns) is preserved. These findings are most consistent with anterior cord syndrome, likely from the posteriorly displaced C5 fragments causing direct spinal cord trauma or anterior spinal artery injury. Anterior cord syndrome and other severe spinal cord injuries can disrupt the autonomic tracts involved in bladder control, leading to acute urinary retention. Therefore, catheterization should be performed to prevent bladder distension and possible injury. anterior cord syndrome bladder control (Choice A) Intravenous steroid (ie, methylprednisolone) therapy may be considered in select patients with acute spinal cord injury. However, oral steroids are not used. In addition, this patient should be NPO until neurosurgical consultation determines whether immediate surgery is indicated. (Choice C) Common indications for central venous access (eg, femoral line) include inadequate peripheral venous access, need for hemodynamic monitoring (eg, measurement of central venous pressure), and infusion of peripherally incompatible solutions (eg, vasopressors). This patient has 2 large-bore peripheral IV catheters, is hemodynamically stable, and has none of these indications. (Choice D) Indications for nasogastric tube insertion include gastrointestinal decompression (eg, ileus, bowel obstruction) and administration of medications or nutrition (eg, unconsciousness, inability to swallow). This patient has none of these indications. Educational objective: In patients with traumatic spinal cord injury, disruption of the autonomic tracts involved in bladder control can lead to urinary retention. Therefore, catheterization should be performed to prevent bladder distension and possible injury. References: Incomplete cord syndromes: clinical and imaging review. (http://www.ncbi.nlm.nih.gov/pubmed/29995620)

A 20-Year-Old Hockey Player Is Brought to the Emergency Department