The Stinger
Cervical spine injuries cause about 6000 deaths and 5000 new cases of quadriplegia per year. These well-known consequences of a "broken neck" usually mean that patients with these injuries are brought by EMS crews to the ER already taped to a rigid and uncomfortable backboard with a stiff cervical collar preventing any movement of the spinal column until we can "clear" them of a dangerous fracture or subluxation.
Not everyone with a neck injury calls 911, however, and some of them walk in themselves. Such was the case of a high school football player whose coaches thought had suffered a "stinger" during a game. After a tackle, he developed neck pain and numbness to the left arm. He left the game and fortunately didn't return, but his parents were concerned enough to bring him to the ER afterward.
When someone walks into the ER on their own power, our clinical suspicion for serious injury is sometimes reduced. I can only assume this is why he wasn't immobilized in triage. When I entered the room, I found him sitting upright in a wheelchair in mild distress from pain, still wearing his sweaty football uniform but not his helmet. He appeared to be holding his head very still so as not to move his neck at all. He was exquisitely tender to the lower midline of his posterior neck. He was slightly weak in his left upper arm but had normal grip strength.
I immediately placed him in a cervical collar and we carefully laid him down on a backboard. I skipped the X-rays and sent him straight to the CT scanner, where he was found to have a burst fracture of C4 and some injuries to the posterior elements of C5.
In Texas it's hard to tell a teenager and his family that he'll never play football again, but the good news overshadowed the bad: after his surgery he left the hospital 3 days later with no neurological deficit whatsoever, one of the luckiest patients I've ever seen.
Not everyone with a neck injury calls 911, however, and some of them walk in themselves. Such was the case of a high school football player whose coaches thought had suffered a "stinger" during a game. After a tackle, he developed neck pain and numbness to the left arm. He left the game and fortunately didn't return, but his parents were concerned enough to bring him to the ER afterward.
When someone walks into the ER on their own power, our clinical suspicion for serious injury is sometimes reduced. I can only assume this is why he wasn't immobilized in triage. When I entered the room, I found him sitting upright in a wheelchair in mild distress from pain, still wearing his sweaty football uniform but not his helmet. He appeared to be holding his head very still so as not to move his neck at all. He was exquisitely tender to the lower midline of his posterior neck. He was slightly weak in his left upper arm but had normal grip strength.
I immediately placed him in a cervical collar and we carefully laid him down on a backboard. I skipped the X-rays and sent him straight to the CT scanner, where he was found to have a burst fracture of C4 and some injuries to the posterior elements of C5.
In Texas it's hard to tell a teenager and his family that he'll never play football again, but the good news overshadowed the bad: after his surgery he left the hospital 3 days later with no neurological deficit whatsoever, one of the luckiest patients I've ever seen.
posted by scalpel at 12:22 PM
19 Comments:
OK, I am really curious here. when you told them he had a broken neck and had just barely (hopefully) avoided being a quadraplegic, were they really concerned about his football career? I mean, really? Or was that something that you sort of projected onto the family?
Hello Scalpel,
According to Marc "Animal" MacYoung, a world-renowned self-defense expert, "about 80 percent of the people with fatal head wounds walk into the hospital."
(Emphasis in original)
What do you think about that?
Jeff Deutsch
I think it's complete lunacy. I've been doing this job (ER) for ten years and seen far too many lethal head wounds and maybe three have walked in.
I agree with Shadowfax. If someone has a head wound that is likely to be fatal, they are much more likely to be in a coma than to be conscious at all, much less walking.
There may have been some projection SF, I mean they didn't ask "will he ever play football again?" or anything, but they were probably thinking it. High school football in Texas is huge, and he was probably worrying about missing his next game, much less the rest of his "career."
Agree with shadowfax. Have rarely seen someone with a serious head injury walk into the hospital. Maybe he's referring to the "lucid interval" described in extradurals...but even that is more a feature of medical books than real life.
Cervical spine injures scare the living daylights out of me though. So easy to miss..both clinically and on plain films!
Oh, and thanks for the link, Jeff, "Animal" does have some good advice, and it makes for interesting reading.
Working in Prehospital in regional australia we see lots of cervical trauma. I reckon in 5 years I've seen about 15 patients like this. My fave was a 45 yo gent who dived headfirst into a pool that was only 4 foot deep. Slit his atlas (C1) in half (on the medial line) and had no deficits. Walked out of the local spinal unit 2 days later wearing a halo brace and went back to his life as a single dad of 4 kids. Good outcome!!
About the nurse who didn't immobilize the patient in triage---You may want to suggest to the nurse mgr at the next ultra-boring multidisciplinary staff meeting that the nurses be required to attend TNCC class if they don't already (basically ATLS for nurses--need to test out on "oral boards"-type trauma scenarios, take a written exam). I'd be shocked if that triage nurse had attended.
Nice work. I can imagine how hard it would be to leave behind for good a favorite sport or hobby or potential career. That he was teteering on the brink of quadriplegia (or worse?) puts it in a perspective.
Yeah Nurse K, a kid in a foot ball uniform that walks in with neck pain and numbness in the arm should get a friggin' collar in triage!
I don't go to lame multidisciplinary staff meetings or any other meetings for that matter. Nightshift FTW!
When I did my practicum on an SCI unit I knew a client that had an previously untreated scateboarding accident. As a drug user he later OD'd only to find that when he woke up--he was a high C injury vent. depend. quad.
SCI's are tough. I had a kid that was playing rugby a few years ago, and he was brought in by BLS collared on a board, but his exam was completely benign, and I mean, no midline tenderness, some slight paraspinous spasm/tenderness, but no focal neuro deficits, still something about his story, and the loud "pop" he heard concerned me. Also, he still had pain in his neck, despite the lack of tenderness on exam. This bothered me, and I decided to scan him and BAM! C3/4 burst fractures. Glad I listened to my gut on that one.
Saw an anterior cord syndrome recently too....poor guy.
My son's best friend was just as lucky. Riding his bike at night with no helmet, one tiny light. Hit by a car and left there in the dark. Wakes up in the ambulance. Two broken vertebrae and a smashed cheekbone. But he has insurance!
Should they have put him on a backboard in triage?? Immobilization in triage is a huge pet peeve of mine. We went through a period where everybody with neck pain was getting a collar and a backboard. As they were generally low acuity patients, they ended up spending a lot of time on the backboard before they were seen. I have now convinced them not to strap everybody to a board, but suspicious spinal injuries now get a collar and walked to a bed.
The way I was taught in residency was: backboards are for transport only. Full spinal precautions = flat on back with rigid c-collar, any necessary movement done as a unit (log roll, etc.)
I would love to know what other people are doing.
Here's one for you, and I'll be writing it up eventually for publication.
I'm in Primary Care, (I'm a PA with 13 years in Internal and Family Medicine who also works Urgent Care) and was watching my son's High School football in the next to the last game of the season. He was the QB, which makes it nice on game film, since we get to see a lot of him!
One of his best friends was a 3 time all league cornerback/safety, a huge hitting 180 pound kid with good makeup speed. He was covering a kid in the flat when the ball was thrown. It sailed over his head and OB, but he put his hands up to try to knock it down, and collapsed! He popped right up, played the next play, then took himself out.
I saw him on the bench being worked on by the training crew, and since I am his primary care provider, went down to see what was up. (He usually came out of a game only when up by 40 points and being dragged by the coaching staff!) He said he had some lateral neck pain, but promptly showed everyone he had full range of motion and he denied any arm, shoulder, or chest pain. I asked if he had ever had pain like this before, and he said yes, about 6 weeks before in the 2nd or 3rd game, but he just thought it was a stiff neck. I asked the head trainer about it, and he told me that the kid had complained of muscle pain, but had no neuro deficits and the pain had resolved in just a couple days.
When I did a C-spine exam, he had definite tenderness right at the base of the skull. We collared him, after a pretty big blowup on his part about wanting to go back in and finish the game. His parents had to come out of the stands to convince him.
CT scan showed a complete anterior/posterior C1 fracture which was just .5mm narrower than the odontoid, keeping it from slipping through.
BUT...there were no bone fragments!!
After discussion with the neurosurgeon, it was determined that he had probably fractured it 6 weeks before, and his tremendous neck musculature was all that kept him from death.
Apart from that lateral, high neck pain, there was never any neuro deficit.
Hip graft, and he has some reduced rotation, but is otherwise back to full activity, minus football. He was cleared to ski, snowboard, etc.
I'd just thought I'd stop by and mention that today I caught a C-spine fracture in a little old lady s/p fall who was not complaining of neck pain. Palpated the C-spine as part of the routine trauma exam (the thing that you're supposed to do as an ER nurse), she had point tenderness, and BAM! C-collared like a mofo. Medics didn't collar her of course. "No complaints of neck pain." *Sigh*
/braggin
I would agree that any significant trauma in an elderly patient should have their neck palpated at triage. I had a similar experience when a little old lady was triaged to fast track and had fallen on the ice. Only complaint was headache. Pushed on the superior cervical spine and she had pain. CT head/neck confirmed cervical fracture.
Good morning Shadowfax,
Given what you've just written on talk-and-die, how significant a portion of eventual head wound fatalities walked into the hospital (or did the equivalent)?
Scalpel, I'd certainly also appreciate your wisdom.
Cheers,
Jeff Deutsch
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