View Full Version : How did they used to screen for a broken neck?
I remember Craig's comment on the uselessness of C-Collars in austere situations. Before advanced scanning (MRI's etc_ ) how did med pesonel Dx for a broken neck and the need for a "halo". When did halo's get invented - anyway? What happened before that? Is there an austere solution to this problem and if so, are C-Collars a part of that plan?
Are there improvised solutions for halo's?
What are Tx guidelines - beyond many months...
thanks,
-t
Austerenurse
06-07-10, 10:47
For diagnosis we relied on X-ray history and clinical exam. With the default setting to over treat versus under treat and conditions expected. CT Scan and MRI was far out of our reach.
X-Ray of the c-spine is becoming a lost art, but if you take high quality images of the right views:
AP [including an open mouth "peg view"]
two lateral shots [one over the verterbal body where you think the problem is and another over the spinous process at that same level, one is enough if you have good x-ray equipment, but two is required if your equipment is limiting]
lateral in flexion and extension view [ if possible and clinically required].
If you cannot see C6/C7 then a swimmers view is required.
People talk about oblique views, but they have never been much use to me.
Some of the options used in the past (or still in the developing world) are:
C-Collars but are of questionable use as they are not all that secure for long term management of fractures in the austere (or any) setting.
A cuirasse made out of plaster (sort of a short Minerva Cast without the forehead piece nor a piece under the arms. See Primary Surgery by King... I think it has a picture)
A molded polythene collar (if you have the equipment and skills to make one)
The full Minerva cast
http://www.flickr.com/photos/casts/3817050453/
http://farm4.static.flickr.com/3434/3817050607_a98c6a5ec7.jpg
http://farm3.static.flickr.com/2680/4209264280_db4cc1bc16.jpg
An improvised halo system, which we had made in Afghanistan without much drama. From a "machine shop" point of view it is quite easy to make.
Or for traction:
The halter (for temporary traction, can be locally made)
http://www.netterimages.com/image/17.htm
Gardner Wells / Cone's / Bartons' tongs
http://www.netterimages.com/image/94.htm (top photo)
Hoen's skull traction
http://www.primary-surgery.org/ps/vol2/html/images/img-0184.png
An improvised halo system with traction applied.
I hope that is of interest.
AN
And lacking any imaging (beyond a tuning fork) - any tips on physical Dx?
Could ultrasound work here?
thanks,
-t
look up nexus spine protocol and the canadian spine protocol for 2 seperate tools to evaluate the c-spine for risk of fx. I think I have posted details previously. It give you the ability to screen 3000 patients with suspected fx down to about 600 that acually need imobilisation and x-rays. of the 600 only about 6-7 will actually have unstable spinal fractures that will benifit from surgical decompression.
thanks to AN! I will review the casting you recomended and try to inflict one on my poor medical assistant tomorrow afternoon. I will post any new ideas from the spine surgeon in my practice.
pa4ortho
Austerenurse
06-07-10, 15:47
Physical Assessment of the Cervical Spine. For those without an x-ray machine.
Canadian C-Spine rule is a great tool. Worth having in your kit. Here are some other tips.
Move slow when you do the examination, if you think it is broken, assume it is broken. Some of these physical examination modalities can cause damage if done too rough or if earlier signs are missed... When you think you have found something stop and decide what you are going to do about it before you keep going.
Inspection
Palpation of the posterior aspect bones while suspine.
- Occuput
- Down the superior nuchal line past the inion
- The mastoid process
- Down the cervical spinous processes on both sides
- To the C7 spinous process (the one the sticks out)
- Up the facet joints
Palpation of the soft tissues
- Zone 1
- Sternocleidomastoid muscle
- Supraclavcular fossa
- Zone 2
- Trapezius muscles from origin to insertion
- superior nuchal ligament
Neurological examination - main muscle groups
- Deltoid for C5
- Biceps for C5 / C6
- Wrist extensors for C6
- Triceps for C7
- Finger extensors for C7
- Finger flexors for C8
- Finger abductors for T1
Neurological examination - reflex
- Biceps for C5/C6
- Brachioradialis for C6
- Triceps for C7
Neurological examination - nerves for sensation
- Lateral arm to anticubular fossa for C5
- Lateral forearm to fingertip for C6
- Middle finger for C7
- Ring and middle finger for C8
- Medial arm for T1
Active range of motion
- Flexion and extension
- Rotation
- Lateral bending
Passive range of motion (use with extreme caution)
- Flexion and extension
- Rotation
- Lateral bending
Neurological testing - Muscle testing against resistance
- Flexion
- Extension
- Lateral rotation
- Lateral bending
Special tests
- Distraction test
- Compression test
- Valsalva test
- Swallowing test
- Adson test
Still nothing is as good as the old x-ray (or a CT) but if you have neither and cannot get to them then... ;-)
Let me know if you have any questions. Not the best organized checklist in the world, but it is a start.
AN
ok so I have a couple more minutes between patients and I had a nice talk with a spine surgeon.
in an austere envirinment where you are definitive care and you have no X-Ray, mri, ct etc... evac is not an option.
a lot more finese and improved treatment can be obtained with the ability to x-ray.
a basic protocol for tx suspected c-spine injury ie failed nexus criteria
do a detailed neuro exam (I can describe in more detail later)
look at mechanism of injury
- forward flexion = anterior compression fx (may be minor or have fragments that can press on the cord)
- axial load (hit top of head) = c1 burst fx (if immobilized this spares the cord well and has good outcomes)
-rearward extention = c2 hangmans fx
-rotation with traction = facet dislocation, (even this will fuse and heal if not reduced as long as no parapalegia/quadraplegia)
The following tx plan is for any of the above injuries and is generic. The goal is to provide basic care while minimizing risk in the majority of patients. It is not ideal by western standards or without risk.
1. no neuro deficits- imobilize 8-12 weeks with a cast vs halo as described by AN
2. radicular or dermatomal focal deficits- most resolve without intervention. no traction as the patient is at risk for unstable fx/ligament instability.
3. parapalegia/quad - in an austrere setting parapalegia can mean the difference between survival and death. this may be an indication to risk traction with gardner wells tongs. This is best done with x-ray. however without xray in light of the risk benifit ratio you can decide with the patient to risk further damage or worsening of the condition with traction. start at 10lbs for 15 min and reassess. add 5 lbs q 15 min up to 25lbs (more with x-ray) see cruchfields rule. 5lbs per level +10 for the head. (ie start at 10lbs + 5 + 5 + 5 for c3 level)
imobilization occiput mandibular to shoulders cast/brace. pad well. provide a cut on both sides to be able to remove it quickly if needed. as described by AN previously. I have never built one as its not standard of care in the developed world and I have not had to tx anyone with one yet. a C collar or philidelphia collar is not adequate. Halo is more secure however you must be able to cleanse and manage pin site infection as a potential complication.
absolutely no smoking.
1day -2 week
fx is mobile based on fracture patern and ligament injury. inflamitory phase of bone healing. imobilize and avoid overhead arm motion. isometric abdominal and leg exercise. bed rest log roll. may sit up and walk as tolerated with assistance use a short board or oregon spine splint to sit up.
2-4 weeks
fx still mobile. reparative phase of healing, initial fibrous healing, otherwise unchanged from above
4-8 weeks
early healing improve stability, maintain imobilization, full wt bearing by now. still needs help to get up as before, otherwise as above.
8-12 weeks
lamellar bone layed down. consider brace removal during this time frame. watch for ligamentous instability. (normaly done with x-ray) gentle active rom at 10-12 weeks, start passsive rom at 12 weeks. isometric cervical exercise as tolerated. independant with mobility and transfers. may use a smaller hard collar when active to provide some suport. swimming, walking, no running or impact. persistant ligamentous instability may cause pain and risk to neuro structures.
what do you think? looking for feedback on this as I have not done this type of tx austere before.
pa4ortho
nexus/canadian feild spine clearing protocols
thanks to Dr Johnson from Wilderness medical associates who has been a role model and who first taught me this at a wilderness advanced life support course. do a search for nexus if you want to see the good science behind this. We over protect the spine in the US due to litigation. A study comparing a hospital in arizona (if you heard the crash from 100yard away you still probably got a backboard,LOL) to one in bangladesh (no backboards ever) showed equivilent outcomes on morbidity and mortality due to iatrogenic injuries from prolonged backboard use causing problems like aspiration leading to death and pressure wounds. In a remote or austere setting they will be on that board for a long time. They will need to be well padded and repositioned frequently or tiped side to side on the board to aleviate pressure wounds. If you ignore this the patient will wiggle around on the board and will not have good imobilization anyway. C collars are for extracting folks from tough spots. they used to be called extraction collars. they are uncomfortable and after prolonged use the patient tucks his chin in it and moves around. use a dense but soft rolled wool blanket as a horse collar crossed and tied in front of the chest to provide long term stability on the trail. remember the roll does not provide axial stability so if you are tipping the patient head up or down as in a steap incline be carefull.
move slow and controled hase makes waste.
1. does the patient have a significant mechanism for injury? if not then stop
if yes then-
2. are they reliable? ETOH, altered LOC, uncooperative, distracting injury, anxious? if not then board them
if yes then-
3. do they have midlinespine tenderness to firm pressure? if not then assess neuro step 4
if yes then board them-
4. neuro intact? sensory sharp vs dull X 4 limbs, no subjective numbness or tingling, no motor weakness to wrist extention foot dorsiflexion and plantar flexion. if intact then ok to get up if not so good then board em.
I use a sked sled and an oregon spine splint combo when I cant take a backboard due to size. I use a backboard when working on or arround vehicles and bulky load is not so critical. I use standard spider straps at times but also use a nylon web improv a lot. 24ft of 1" nylon web is used (2 individual rescue "ropes" from team members) tie a loop in the mid point. If its a pre prepared item lightly bleach one so it is a slightly different color. take about 8-10 inches on the ends and fold them over lengthwise and sew them like that to make it semi ridgid. this way it threads the web on the backboard handles like a needle pulling thread. start at the head and criss cross your way down the backboard lacing them to the board like a shoelace. lace over the ankle and under the oposite foot to form a web below the foot and tie the ends together. make it snug but so they can still breath well. If they vomit grab the handle at the top of the board and pull it more snug+ as you turn them so they are laced tight to the board as they get spun on their side or even a little face down.
Austerenurse
06-07-10, 19:32
o
what do you think? looking for feedback on this as I have not done this type of tx austere before.
pa4ortho
Looks good to me... well thought out.
AN
absolutely no smoking.
why?
On a strictly editorial suggestion - what's wrong with this timeline?
1day -1 week
2-4 weeks
4-8 weeks
8-12 weeks
Very good and interesting replies. Thanks! Followed most of it, but I need a date with an A&P text and my medical dictionary for a few things...
On the plaster - that's a lot! any thoughts on recycling it? I've got enough casting stuff for 6-12 casts... and then I saw those pics...
on keeping drill holes clean and uninfected - suggestions?
good writeup! Like others in diff threads, it could use combining.
-t
Austerenurse
06-08-10, 00:46
The verdict is still out with respect to pin site care as none has proven scientifically to be better than another.
Pin site infection is common (20% of patients) with halo vest. If you see redness and drainage take a culture and start on oral antibiotic. If antibiotics do not seem to work, move the pin to a new site. For more information see: Bono, C. M., Garfin, S. R., Einhorn, T. A., & Tornetta, P. (2004). Spinal orthoses. In C. M. Bono & S. R. Garfin (Eds.), Spine: Orthopedic surgery essentials (pp. 285-296). Philadelphia: Lippincott Williams & Wilkins.
Some of the common cleaning methods are once to three times a day:
Normal saline
50% normal saline with 50% hydrogen peroxide
Chlorohexadine
Betadine soaked gauze wrapped around the pin
My thoughts are (again un-scientifically proven, but work for me) assessment and cleaning once to twice a day. Clean with a normal saline or cotton applicator and then ensure the site is dry. If there is crust or drainage clean with cotton applicator and/or gauze soaked in normal saline. If that fails to dislodge the crust, soak a gauze pad in normal saline and apply around the pin for 20 minutes and then wipe it off with the cotton tipped applicator and/or gauze soaked in normal saline. I do not recommend using chlorhexidine, betadine, or hydrogen peroxide. I also do not recommends leaving anything around the base of the pin. Others will disagree.
AN
the only reason to cover the pin sites is to keep insects off and not freak out anxious patients/moms who dont want to see the pins in the skin
One of the chalanges of maintaining a halo vest is pin site tension. start at 2 ft lbs of pressure and alternate adding 2 lbs to oppising pins diagonaly until you reach 8 ft lbs of pressure. recheck q week. if pins get loose its unstable and they can slip. if they are too tight they dig in and bone will remodel away from the pins resulting in loosening about a week later. eventually the pins can erode the inner table of the skull.
its a race between bone remodeling at the fx site and at the pin site.
pa4ortho
when palpating the spine for fx many people dont push hard enough to find the pathology because they are too afraid of hurting the patient. The goal of the palpation is to find pain if present. If you lightly press on the soft tissues you wont find it.
start with light midline pressure gradually adding more pressure then do the same on bilateral facets just to the side of midline, both sides at the same time. push on someone who is not injured to practice. if you feal the spine pain free lightly rebound from less than 1mm of subluxation that is normal and you are pushing hard enough. Develop the feel for the alignment and rotation of the facets as well as the slight motion on the facets when pressure is applied. practice practice practice.
learning basic chiropractic/ osteopathic manipulation can greatly enhance these palpation skills for subtle findings. .....its also is a great tool for keeping the team going after long days in body armor or heavy labor (farming/gardening)
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