Clinical scenario 2 - Anna
Teaching/learning points:
- Immobilisation in children
- Anatomical differences
- SCIWORA
The triage nurse rushes into resuscitation with nine year old Anna and her parents. Anna is in her father’s arms. She has fallen from their first-floor balcony onto the lawn below. Her fall was not witnessed but heard by her parents, who immediately found her on her back in the garden crying. Rather than calling an ambulance, Anna’s parents brought her to emergency in their car.
The triage nurse is concerned Anna has fallen a significant height (greater than twice her standing height). Anna initially appears alert and very distressed. She is complaining of severe neck and back pain. Her respiratory rate is 26/min, saturations 100% in air, heart rate 110bpm, blood pressure 100/60. Based on her mechanism of injury, Anna was immediately secured on a spinal board with three straps, a hard cervical collar and sandbags.
The following eight questions refer to Anna’s clinical scenario.
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Question 07 What is the best plan for an initial assessment of Anna? Identify the best order for the following steps by choosing from the answer options below:
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| Breathing> Airway with Cervical Spine control> Circulation with haemorrhage control> Disability or neurological status> Exposure | ||||||||||
| Disability or neurological status >Exposure >Breathing >Airway with cervical spine control >Circulation with haemorrhage control | ||||||||||
| Exposure >Breathing >Disability or neurological status >Airway with cervical spine control >Circulation with haemorrhage control | ||||||||||
| Airway with cervical spine control >Breathing >Circulation with haemorrhage control >Disability or neurological status >Exposure | ||||||||||
| Circulation with haemorrhage control >Disability or neurological status >Exposure >Breathing >Airway with cervical spine control | ||||||||||
| Check answer | ||||||||||
ExplanationAnswer: Airway with Cervical Spine control> Breathing> Circulation with haemorrhage control> Disability or neurological status> Exposure In trauma, like resuscitation, an ABC approach is adopted for patient assessment and management (Airway, Breathing, Circulation, Disability, Exposure). In the case of trauma however, the mnemonic is modified to:
While in reality, assessment of these areas will run in parallel with a large team, rather than in series with one person, it is important to remember this sequence so as to identify the greatest threats to life first
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*Question 08 You are able to engage and calm Anna down. On rapid assessment, you do not identify any airway, breathing or circulation concerns. On neurological assessment at this stage, Anna is alert, anxious but appropriate, GCS E4 V5 M6, her pupils are equal and reactive. Her peripheral tone, power, reflexes and sensation appear normal. At this stage, it appears safe to examine Anna’s spine further. What is the best procedure for examining Anna’s spine?
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| A, B, C, D |
| B, C, D, E |
| E, C, A, B |
| B, A, E, D |
| B, C, E, D |
| Check answer |
ExplanationAnswer: A-B-C-D In addition to rapid neurological examination, inspection and palpation of the bony spine, ongoing investigation for spinal injury is through looking for pain, swelling, steps and deformity. A per rectal examination for anal tone (routine in adults) is of uncertain additional benefit in children compared to perianal sensation. Considering the distress caused, it is not routine in children. A log roll is performed as part of E) Exposure. In a log roll, multiple team members carefully roll a patient, maintaining spinal alignment at all times, to allow examination of the spine while minimising its movement. |
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*Question 09 On examination, Anna has generalised pain in the midline from C2 to T1 and additional pain around T9-T10. There is no obvious bruising, swelling or deformity, and no additional findings lateral to the midline. Which one of the following is the next appropriate management step? |
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| Urgent MRI Spine |
| Plain x-rays of the spine |
| Analgesia |
| CT Spine |
| Ultrasound |
| Check answer |
ExplanationAlthough imaging will be necessary in due course, providing suitable pain relief as soon as possible is mandatory. Though choice of analgesia, route and dose must be carefully considered, it is unlikely any clinically significant injury will be masked by analgesia alone. |
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Question 10 Following administration of pain relief, you consider further imaging options to evaluate Anna’s potential spinal injuries fully. As part of the initial primary survey, a lateral c-spine, chest and pelvic film were performed in the resuscitation bay. Is the lateral c-spine radiograph alone adequate to rule out a fracture? |
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| Yes |
| No |
| Check answer |
ExplanationWhile in some studies a cross-table lateral c-spine film has demonstrated good sensitivity, the obvious answer is ‘no’. In all bony injuries, especially the neck, multiple views are necessary to fully evaluate the structure. Conventionally with cervical spines we perform three views: a lateral, antero-posterior and odontoid peg view where possible. |
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*Question 11 On examination of the lateral c-spine film, the vertebral body of C2 appears to sit forward on that of C3, as illustrated in the accompanying image of a two year old child. Reference: UpToDate www.uptodate.com
What could this indicate? |
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| A fracture or dislocation |
| Normal variant |
| Both of the above |
| Check answer |
ExplanationEither finding is not infrequently found on lateral x-rays in children. When laid on a flat surface, with comparably lax or flexible supportive ligaments, children can lose the curve seen in adult c-spine films, having a straighter alignment of the vertebral bodies, with the appearance of C2 sitting forward or subluxing on C3, or C3 on C4. This is referred to as Pseudosubluxation. It should not be confused with true subluxation, caused by a bony or ligamentous injury compromising the stability of the cervical spine and threatening the integrity of the spinal canal. |
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*Question 12 Following analgaesia, Anna is sent to radiology for further plain film views of her cervical and thoracic spine. No bony abnormality is identified. Which one of the following is the next best step in management? |
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| Remove the collar |
| Mobilise the patient |
| Reassess the patient |
| Check answer |
ExplanationAnna needs to be reassessed. Normal imaging does not clear the patient. Though a fracture is less likely, there could still be a significant soft tissue or ligamentous injury. Furthermore, there could still be an injury to the spinal cord, which, if mobilised inappropriately, could be damaged further (Spinal Cord Injury Without Radiological Abnormality - SCIWORA). The only way to clear the patient and mobilise them is following careful clinical assessment. |
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*Question 13 You return to the bedside to reassess Anna. What clinical features is it important to look for when clearing the cervical spine? |
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| Midline pain |
| Focal neurological deficit |
| Distracting injury |
| Intoxication |
| Decreased level of consciousness |
| All of the above |
| Check answer |
ExplanationAll of he above are correct. These are referred to as the NEXUS criteria (Hoffman et al., 2000 NEJM 343(2):94-9). If the above criteria are absent clinically, the likelihood of a clinically significant neck injury is very small. These criteria have been well validated in adults and increasingly in children over the age of two. Following reassessment, you are satisfied at this stage that Anna has no major spinal injuries. You proceed to remove spinal precautions and transfer her to a less intensive area of the department for further observation. * The Children’s Hospital at Westmead uses the following approach to managing neck injuries:
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