Electrocution without electricity

[Arctickat]

I don't see anything significant in C1-3, C4-6 on the other hand appear to be compressing the cord.

[DartmouthDave]

Hello,

It could be an incompleted spinal cord injury: Central Cord Syndrome.

He was punched and hyperextensed his neck backwards.

A collar with the HOB 15-30 degrees should be adequate for transport.

Cheers

[mobey]

Hey guys, sorry for the delay.

I am quite curious as to what ERDoc's take on the x-ray is.

Good call Dave, as usual.

The sending GP stated the following= Central cord syndrome with possible C3 dorsal spinous process fracture (looks like the tip of a thumb broke off on the back portion of the vertebra)

Upper extremity weakness was confirmed after analgesia.

I have no further information, as he was transfered to a tertiary care centre.

Central Cord Syndrome:

• 
  Symptoms of central cord syndrome occur following trauma (most commonly falls) and consist of upper and lower extremity weakness, with varying degrees of sensory loss. Pain and temperature sensations, as well as the sensation of light touch and of position sense, may be impaired below the level of injury.
  
• 
  
  Physical findings related to central cord syndrome are limited to the neurologic system and consist of upper motor neuron weakness in the upper and lower extremities. This impairment can be described as follows:
  
  • 
    Impairment in the upper extremities is usually greater than in the lower extremities and is especially prevalent in the muscles of the hand.
    
  • 
    Sensory loss is variable, although sacral sensation is usually present. Anal wink, anal sphincter tone, and Babinski reflexes should be tested.
    
  • 
    Muscle stretch reflexes may initially be absent but will eventually return along with variable degrees of spasticity in affected muscles.
    

  Surgery is rarely indicated because of the inherently favorable prognosis for patients with central cord syndrome.

  http://emedicine.medscape.com/article/321907-overview

[DwayneEMTP]

Man, great scenario.

I find it interesting that they give that description, upper and lower extremity weakness, etc, without a reference for the location of the cord damage? I'm trying to remember why the location wouldn't be relevant without Googling. I've got a tickle, but can't really resolve it in my head.

I'll wait for the explanation of my betters before researching...

[ERDoc]

This is a classic mechanism for a hangman's fracture, but with a true hangman you get a fx of C2 with subluxation of C2 on C3. The xray that Mobey provided looks like a C3 fx. It's hard to assess below the C3 level but what is visible looks okay. This dude needs a CT and an orthopod.

[mobey]

This dude needs a CT and an orthopod.

Great suggestion here Doc

Reflecting on this call, I probably could have gotten orders to bypass the local clinic direct to trauma centre query spinal fracture with neuro deficit.

Some might say the films shot were unnessasary radiation as CT is mandatory in these patients.

As a patient advocate, I could have spared him 4-5 shots of x-ray by bypassing.

Dwayne: I also need to read up on CCS, so I can't help.

Hope to see ya over at last nights patient

Thx all.

[Arctickat]

I don't see anything significant in C1-3, C4-6 on the other hand appear to be compressing the cord.

Oops, guess I can't count.

[ERDoc]

Don't sweat the xrays Mobey. There is debate in the EM community over the utility of c-spine xrays. If you cannot clearly see the top of T1 you cannot clear the spine. There are so many people where you cannot see to T1 that you end up having to CT any way. So, do we try to limit the radiation from the CT and do the xrays or do we skip the radiation from the xrays and just go to CT? It's a catch 22. Once you find something on the xrays, CT is needed.

[zippyRN]

unless and until you can rule out some kind of neuro pathology ... whether that's a CVA , a neck injury from the 'scuffle ' ( think central cord syndrome) ...

[ERDoc]

What kind of CVA produces bilateral pain?