Author(s): Patrick Carter, Daniel Wachter, Rockefeller Oteng, Carl … · 2016-10-10 · Brown...

Author(s):PatrickCarter,DanielWachter,RockefellerOteng,CarlSeger,2009-2010.License:Unlessotherwisenoted,thismaterialismadeavailableunderthetermsoftheCreativeCommonsAttribution3.0License:http://creativecommons.org/licenses/by/3.0/

WehavereviewedthismaterialinaccordancewithU.S.CopyrightLawandhavetriedtomaximizeyourabilitytouse,share,andadaptit.Thecitationkeyonthefollowingslideprovidesinformationabouthowyoumayshareandadaptthismaterial.Copyrightholdersofcontentincludedinthismaterialshouldcontactopen.michigan@umich.eduwithanyquestions,corrections,orclarificationregardingtheuseofcontent.Formoreinformationabouthowtocitethesematerialsvisithttp://open.umich.edu/education/about/terms-of-use.Anymedicalinformationinthismaterialisintendedtoinformandeducateandisnotatoolforself-diagnosisorareplacementformedicalevaluation,advice,diagnosisortreatmentbyahealthcareprofessional.Pleasespeaktoyourphysicianifyouhavequestionsaboutyourmedicalcondition.Viewerdiscretionisadvised:Somemedicalcontentisgraphicandmaynotbesuitableforallviewers.

CitationKeyformoreinformationsee:http://open.umich.edu/wiki/CitationPolicy

Use+Share+Adapt

MakeYourOwnAssessment

CreativeCommons–AttributionLicense

CreativeCommons–AttributionShareAlikeLicense

CreativeCommons–AttributionNoncommercialLicense

CreativeCommons–AttributionNoncommercialShareAlikeLicense

GNU–FreeDocumentationLicense

CreativeCommons–ZeroWaiver

PublicDomain–Ineligible:WorksthatareineligibleforcopyrightprotectionintheU.S.(USC17§102(b))*lawsinyourjurisdictionmaydiffer

PublicDomain–Expired:Worksthatarenolongerprotectedduetoanexpiredcopyrightterm.

PublicDomain–Government:WorksthatareproducedbytheU.S.Government.(USC17§105)

PublicDomain–SelfDedicated:Worksthatacopyrightholderhasdedicatedtothepublicdomain.

FairUse:UseofworksthatisdeterminedtobeFairconsistentwiththeU.S.CopyrightAct.(USC17 § 107)*lawsinyourjurisdictionmaydifferOurdeterminationDOESNOTmeanthatallusesofthis3rd-partycontentareFairUsesandweDONOTguaranteethatyouruseofthecontentisFair.Tousethiscontentyoushoulddoyourownindependentanalysis todeterminewhetherornotyourusewillbeFair.

{Contentthecopyrightholder,author,orlawpermitsyoutouse,shareandadapt.}

{ContentOpen.Michiganbelievescanbeused,shared,andadaptedbecauseitisineligibleforcopyright.}

{ContentOpen.MichiganhasusedunderaFairUsedetermination.}

Advanced Emergency Trauma Course

GhanaEmergencyMedicineCollaborativePatrickCarter,MD∙DanielWachter,MD∙RockefellerOteng,MD∙CarlSeger,MD

C-SpineandSpinalCordTrauma

Presenter:CarlSeger,MD

Epidemiology

  Spinal Trauma- 10,000 new cases eachyear, with over 200,000 spinal injuryvictimslivinginUS

  55%ofspinalinjuriesoccurintheC-spine  15% in the thoracic, lumbar, and sacralregions

  10% of pts with c-spine injury haveanothervertebralfracture

GhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourse

Spinal Trauma

  Spinaltraumahasahugeimpactphysically,financially,andemotionallyonsociety

  Propertreatmentcanminimizefurtherdamage

  Immobilizationequipmentiseasytouse,inexpensive,andreadilyavailable

  OurdutyasEMphysiciansistoprovidepropercareand“DoNoHarm”

Can we make an impact?

  “3-25%ofcasesofpermanentneurologicimpairmentafterspinaltraumahavebeenattributedtoinjudiciousmanipulationbyparamedicalpersonnel,examiningphysicians,orradiologytechnicians.”

FranciscodeAssissAquinoGondim,MD,e-medicine-SpinalCordTrauma

Prevention is key!

 Withproperapplicationofspinalprecautions,wecanpositivelyimpactpatientoutcomes

Evolution of Spine

  PrehistoricMan•  Hunchedshoulders•  Strongposteriorneckmuscles

  ModernMan•  Shouldersdropaway,headelevates•  Atrophyparaspinalmuscles•  Sacrificeprotectionforincreasedrangeofmotion

http://commons.wikimedia.org/wiki/File:Human_evolution.svg

Modern Man   IncreasedIntellect,sameaggression  Horsedrawncarriagesreplacedbymachine-poweredvehicles

  Fistsandclubsgavewaytoknivesandguns  Newandinventivewaystoinflictinjurytospine

Basic Anatomy   7Cervical  12Thoracic  5Lumbar  5Sacral  4Fused  Coccygeal

  LordoticCurves  KyphyoticCurves

Gray’sAnatomy(Wikipedia)

Functional Anatomy Review   VertebralColumn•  33Vertebrae

  Vertebrae=Body+Arch•  VertebralArch

  Pedicles  Laminae  Processes

  Ligaments•  Anterior/PosteriorLongitudinal•  VertebralArchLigaments

  LigamentumFlavum  SupraspinatousLigament  InterspinousLigament  IntertransverseLigament  CapsularLigament

  IntervertebralDisks•  NucleusPropulsus•  AnnulusFibrosus

Functional Anatomy Review

UweGille(Wikipedia)GhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourse

Spinal Stability   CervicalSpine•  AnteriorColumn•  PosteriorColumn•  Disruptbothcolumnstobeunstable

  ThoracolumbarSpine•  DenisClassification•  AnteriorColumn•  MiddleColumn•  PosteriorColumn•  Disrupt2columnstobeunstable

https://commons.wikimedia.org/wiki/File:Cervical_vertebra_english.png

Normal Cervical Spine

http://www.trauma.org/archive/spine/images/cspinealign.jpg

http://www.trauma.org/archive/spine/images/cspineLAT.jpg

Injury Patterns   Acutespinalinjuriescanbemosteasilyclassifiedaccordingtothemechanismoftrauma

  CategoriesincludeFLEXION,FLEXION-ROTATION,EXTENSIONandVERTICALCOMPRESSIONinjuries

  CanalsoincludeinclassificationwhetherornotaparticularinjuryisSTABLEvs.UNSTABLE

Cervical Spine Injuries   FlexionInjuries•  Wedgecompressionfracture•  Flexionteardropfracture•  ClayShoveler’sFracture•  BilateralFacetDislocation

  FlexionRotation•  Unilateralfacetdislocation

  VerticalCompression•  JeffersonBurstFracture•  BurstFracturesofLowerCervicalSpine

  HyperextensionInjuries•  Avulsionfractureofanteriorarchofatlas•  Extensionteardropfracture•  Posteriorarchofatlasfracture•  Laminarfracture•  Hangman’sFracture

  LateralFlexion•  UncinateProcessFracture

  UpperC-spineInjuries•  Occipitoatlantaldissociation

Flexion Injuries   FlexioninjuriesinvolvingC1-C2cancauseatlantooccipitaloratlantoaxialdislocation,withorwithoutfractureoftheodontoid

  Atlas=C1,Axis=C2  Unstableduetothelocationandrelativelackofmuscleandligamentoussupport

Flexion injury

  OdontoidFxwithanteriordislocationSourceUndetermined SourceUndetermined

Flexion Injury   InpureflexioninjurybelowC2,forceisexpendedonthevertebralbodyanteriorly,resultinginasimplewedgefracture

  Simplewedgefracturesarestable  Evengreaterflexionforcesawedgeshapedfragmentoffanterior-inferiorportionofvertebralbody,calledaflexionteardropinjury

  Usuallyincludesligamentousinjuryandisunstable

Wedge Fracture

http://faculty.washington.edu/alexbert/MEDEX/Winter/EM1DisordersSpine.htmhttp://emedicine.medscape.com/article/94234-media

Flexion Teardrop Fracture

SourceUndetermined SourceUndetermined

Flexion Injury   InAustraliaduringthe1930’s,certainclayminerssustainedauniqueinjury

  Whilestrainingwithheavyshovelfulofclay,theabruptflexionofheadinoppositiontothestrongsupraspinousligament,resultedinavulsionfractureofspinousprocess

  ClayShoveler’sfractureismoreoftenseentodayduetodirectblow,i.e.poolcueorbaseballbat,orfromsuddendecelerationinMVC

  Stableinjury,noneurologicinvolvement

Clay Shoveler’s

http://faculty.washington.edu/alexbert/MEDEX/Winter/EM1DisordersSpine.htmhttp://emedicine.medscape.com/article/94234-media

Extension Injury   MostwellknownistheHangman’sfracture  Popularexecutionstyleinpreviouseras  “ShortDropwithSuddenstop”.Thedropwaspreferredtothedangle

  Theskullisthrownintoextremehyperextensionresultinginbilateralpediclefracturesofaxis

  Unstable,butneurologicalinvolvementisminimal,thereforedeathusuallyduetostrangulation,notcorddamage

Hangman’s Fracture

http://commons.wikimedia.org/wiki/File:Hangman%27s_fracture.JPG

Vertical Compression Injury   Example=JeffersonFracture  Forceistransmitteddownthroughskullandoccipitalcondylestosuperiorarticularsurfacesoflateralmassesofatlas

  Sinceatlasisaring,thisforcepushesthemassesoutwardresultinginfracturesofanteriorandposteriorarches,anddisruptionoftransverseligament

  ExtremelyUNSTABLEGhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourse

Jefferson Fracture

SourceUndetermined

Jefferson Fracture

SourceUndetermined

Injuries of Thoracic and Lumbar Spine

 CompressionFractures BurstFractures FlexionDistractionFractures

  CompressionFractures

http://emedicine.medscape.com/article/397896-media

  BurstFractures

http://emedicine.medscape.com/article/248236-media

Injuries of Thoracic and Lumbar Spine   FlexionDistractionFractures–ChanceFx

http://radiopaedia.org/images/143729

Pathophysiology of Acute Fractures

  Directcompressionofneuralelementsbybonefragments,discmaterial,andligamentsleadstodamageofthecentralandperipheralnervoussystem

  Bloodvesselcompressionanddisruptioncausesischemia

  Massivecordswellinghappenswithinminutesatthelevelofinjuryandleadstosecondaryischemia

Spinal Cord Lesions   Overview•  CompleteSCI=Nomotororsensoryfunctionbelowinjurylevel•  IncompleteSCI=AnySensory/motorfunctionbelowlevelofinjury

  SpinalCordTracts•  Corticospinaltract=Descendingmotorpathway•  Spinothalamictract(anterior)=Pain/Temperature•  DorsalColumnPathway=Vibratory/Proprioception

  Incompletespinalcordlesions•  Anteriorspinalcordsyndrome•  Posteriorspinalcordsyndrome•  CentralCordsyndrome•  BrownSequardSyndrome

SourceUndeterminedGhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourse

Pathophysiology   PrimaryInjury•  MechanicalInjury

  SecondaryInjury•  VascularAbnormalities•  FreeRadicals/LipidPeroxidation•  Excitotoxicity

  Electrolytedisturbances•  Inflammation

  Edema

SourceUndetermined

Cord Syndromes   CentralCordSyndrome  AnteriorCordSyndrome  PosteriorSpinalCordSyndrome  BrownSequardSyndrome

Incomplete Spinal Cord Syndromes   AnteriorSpinalCordSyndrome•  Corticospinalandspinothalamictractsinjured•  Preservationofposteriorcolumnpathway•  Etiology

  Anteriorspinalcordtrauma  Flexionofcervicalspinecausingcordcontusion

  Thrombosisofanteriorspinalartery

SourceUndetermined

Incomplete Spinal Cord Syndromes

  PosteriorSpinalCordSyndrome•  Rarecondition•  Injurytodorsalcolumn•  Preservationofcorticospinalandspinothalamicpathways•  Etiology

  Penetratingtraumatoposterioraspectofcord  Hyperextensioninjurywithvertebralarchfracture

SourceUndetermined

  CentralCordSyndrome•  Injurypreferentiallyaffectscentralportionofcord•  Lossoffunctionofcentralfibersofcorticospinalandspinothalamictracts•  Decreasedstrengthandpain/temperatureofupperextremitiescomparedwithlowerextremities•  Etiology

  Hyperextensioninjuries  Centralspinalstenosis  Disruptionofnormalbloodflow

Incomplete Spinal Cord Syndromes

SourceUndetermined

Incomplete Spinal Cord Syndromes   BrownSequardSyndrome•  Transversehemisectionofspinalcord•  Ipsilaterallossofmotorfunction,proprioceptive/vibratorysensation•  Contralaterallossofpain/temperaturesensation•  Etiology=PenetratinginjuryorLateralcordcompression

SourceUndetermined

Spinal vs. Neurogenic Shock   SpinalShock•  Temporaryphenomenoncharacterizedbylossofallspinalcordfunctioncaudaltolevelofinjury•  Symptoms=Flaccidparalysis,Hypotonia,Areflexia,Priapism•  Typicalduration=24-72hours•  Resolution=ReturnofBulbocavernosusreflex•  Outcome=Spasticparesis,hyper-reflexia

  NeurogenicShock•  Typeofdistributiveshockcharacterizedbylossofadrenergictoneduetosympatheticdenervation•  ClassicTriad=Hypotension,Bradycardia,Hypothermia•  Management=IVF,Vasopressorsupport,Atropine

Spinal Shock vs. Neurogenic Shock

  SpinalShock-theflaccidityandlossofreflexesseenafterspinalcordinjury.Thecordmayappeardestroyedbutactuallymayregainfunctionlatter

  NeurogenicShock-destructionofthedescendingsympatheticpathwaysofthespinalcord.Resultsishypotensionandbradycardia.Ptswillrequirevasopressorsandatropineaswellasfluid.

Management   Immobilization  ClinicalC-spineClearance•  Whentogetimages

  ThoracicandLumbarSpinalImmobilizationandClearance

  ManagementofCervicalandThoracolumbarfractureswithoutspinalcordinjury

Aims of Immobilization   Preventfurtherdamage-ProtecttheCord  Holdthespineinacomfortable,anatomicallycorrectway

  Preventmovementofthespine  Allowforsafeconcurrentmanagementofotherinjuries

Options for Immobilization  AnatomicalRegions• Head• Neck• Body

Head Immobilization  Manual-Hands,Legs  SimpleAssistDevices-Sandbags,Towels,FoamPads

  AdditionalDevices-Straps  Head/Neckimmobilizer

Head Immobilization

Cdang(Wikipedia)

Head Immobilization   Studycompared3methodsduringsimulatedvehiclemotion,(Spine1999;24)•  Sandbags•  Headband•  Styrofoamwedges

  Wedgesslightlybetter  Keyisbodyimmobilization

Neck Immobilization  Collars• Philadelphia• Stiffneck• Otheroptions

Neck Immobilization

Emrgmgmtca(Wikipedia)

Neck Immobilization   AnnEmergMed1992;21:1185-1188•  ComparedCcollarwithAmmermanHaloorthosis,withandwithoutspineboard•  Photographiccomparisonduringtransport•  Conclusion:

  Arigidcervicalcollarandaspineboardprovidesignificantlybetterimmobilizationthanthecollaralone.FurtherimmobilizationisprovidedbyanAmmermanhaloorthosis

Body Immobilization

 Backboards•  Importantfortransportingpatientsandkeepingthemfrompossiblyinjuringthemselvesfurther

Back Boards

Cdang(Wikipedia) Ryan.mco(Wikipedia)

Complications associated with Spinal Immobilization

  Pain  Increasedriskofpressuresores  Aspirationandlimitedrespiratoryfunction•  Increasedriskofaspiratingemesiswhilestrappedonbackboard•  Markedpulmonaryrestrictiveeffectofappropriatelyappliedentirebodyspinalimmobilizationdevices

When to get an X-ray  Patientsinvolvedinatraumaticevent• withmidlinetenderness• Withneurologicdeficits• Alteredlevelofconsciousness• Patientswhoareintoxicated

C-spine X-ray   LateralView• MustseetothetopofT1forfilmtobeadequate• Mayneedswimmersview• Willsee90%ofcervicalspinefractures

 Odontoidview• Mustincludeentireprocessandrightandleftc1andc2articulations

Flexion and Extension Films  ObtainedininjuredptswithoutanAMS,andptswhohaveneckpainwithoutfractureonAP,Lateralandodontoidviews

  Lookingfor•  Instability•  Ligamentousspineinjury

CT Scan  MoreSensitive  Ifhighsuspicionforinjuryandhaveinadequatex-ray,CTiswarranted

How do you clear a C-spine Injury?

  Twostudies-NEXUSvs.CanadianCspine• Nexus

 Patientsrequiredtomeet5criteria• Nomid-linetenderness• Nofocalneurologicaldeficit• Normalalertness• Nointoxication• Nopainful,distractinginjury

NEXUS study   PatientswhounderwentC-spineX-rayforblunttrauma

  34,069patientsincludedinstudy  818patientshadaC-spineinjury  8ofthesepatientsmetall5criteria  4209non-injuredpatientsmetall5criteria

NEXUS Study   Problems• Managementstressors•  Failuretodiscriminatewhatpainissignificant• Whatisadistractinginjury?• Howdrunkisintoxicated?

Canadian C Spine Rule

SourceUndetermined

Canadian C Spine Rule   TheauthorsconcludethattheCCRdecisionruleismoresensitivethanNEXUSforidentificationofclinicallyimportantC-spineinjuriesandalsoismorespecific,therebydecreasingthenumberofunnecessaryC-spineradiographs

  Problemsinclude•  Requiresactiveneckrotation(10%excluded)•  Whatisa“DangerousMechanism”?

Methylprednisolone   Controversialtreatmentmodalityforbluntspinalcordtrauma

  NationalAcuteSpinalCordInjuryStudies(NASCIS)  Subsequentstudies•  Pointillart(2000)•  Matsumoto(2001)

  MechanismofAction•  Inhibitionoffreeradicalinducedlipidperoxidation

  Currentrecommendedregimen•  Methylprednisoloneprescribedasabolusintravenousinfusionof30mg/kgofbodyweightover15minwithin8hoursofacuteclosedspinalcordinjury

•  Followed45minlaterbyaninfusionof5.4mg/kgofbodyweightperhourfor23hours

Summary   Spinalimmobilizationcanreducethelikelihoodofneurologicaldeteriorationinpatientswithunstablec-spineinjuriesfollowingtrauma

  Immobilizationoftheentirespinalcolumnisnecessaryinpatientsuntilaspinalcord/columninjuryhasbeenexcludedoruntiltheappropriatetreatmenthasbeeninitiated

Summary   Acombinationofrigidcervicalcollarwithsupportiveblocksonarigidbackboardwithstrapsiseffectiveatachievingsafe,effectivespinalimmobilizationfortransport

  Spinalimmobilizationdevicesareeffectivebutcanresultinpatientmorbidity.Theyshouldbeusedforsafeextricationandtransport,butshouldberemovedassoonasdefinitiveevaluationisaccomplishedortreatmentinitiated

Summary   Methylprednisolonetherapyforacutespinalcordinjuryiscontroversialwithonlybenefitwhenadministeredwithin8hoursofinjury

  CurrentMethyprednisoloneregimen:•  Methylprednisolonebolusintravenousinfusionof30mg/kgofbodyweightover15minwithin8hoursofacuteclosedspinalcordinjury•  Followed45minlaterbyaninfusionof5.4mg/kgofbodyweightperhourfor23hours

  AppropriateclassificationofSCIpatientswithinEDtoensurepromptevaluationandtreatment

  CommunicationbetweenEDstaffandresidentsiskeytolimitingerrorsandprovidingappropriatecare

Questions?

ErinSilversmith(Wikipedia)

References   Baron,B.,Thomas,S.SpinalCordInjuries,inEmergencyMedicine:AComprehensiveGuide.Tintinalli,Editor.2004,McGraw-Hill.p.1569-1583.

  AmericanCollegeofSurgeons.SpineandSpinalCordTrauma,inAdvancedTraumaLifeSupportforDoctors7thedition.2004.p.177-204.

  Lin,M.,Mahadevan,S.SpineTraumaandSpinalCordInjuries,inEmergencyMedicine.Adams,Editor.2008,SaundersElsevier.P.765-783

Author(s): Patrick Carter, Daniel Wachter, Rockefeller Oteng, Carl … · 2016-10-10 · Brown...

Documents

Data Protection 2020 - templars-law.com...SKW Schwarz Rechtsanwälte: Nikolaus Bertermann 150 Ghana Addison Bright Sloane: Victoria Bright & Justice Oteng 190 Isle of Man DQ Advocates

Project: Ghana Emergency Medicine Collaborative Document Title: Pulmonary Embolism Part 2 (2012) Author(s): Rockefeller A. Oteng, M.D., University of Michigan

Brown-Sequard Syndrome after an Accidental Stab Injury of ... · Brown-Sequard Syndrome after an Accidental Stab Injury of Cervical Spine: A Case Report Soo Dong Park, MD, Sang Woo

Brown-Sequard Syndrome...อย ในเกณฑ ปกต ตรวจ deep tendon reflex พบว าแขนและขาด านซ าย 3+ ,แขนขาและด

Cervical 2 Hemisection Model The Comparation of Two

Hemisection a Preservative Approach to Endodontic ...oralhealth.ro/volumes/2015/volume-3/Paper800.pdf · Hemisection a Preservative Approach to Endodontic-Periodontic Lesion: Case

02 Alfred A Oteng Yeboah - satoyama-initiative.org · • Sacred groves • Traditional reserves (forest, grassland, mangroves) • Agricultural crop fields and intensive farming

Hemisection: A ray of hope for the management of ...ijmdcr.com/eJournals/_eJournals/89_CASE REPORT.pdf · Under 2% lidocaine local anesthesia, hemisection was started from the coronal

Hemisection as a Conservative Management of Grossly

Hemisection a Preservative Approach to Endodontic ... · Department of Conservative Dentistry & Endodontics, VSPM’s Dental College & Research Center, Nagpur, India Abstract Endodontic–periodontal

wHiCHEVEWsltftrMflBEH^OTENG HIGH COURT, PRETORIA

Brown Sequard Syndrome

LSHTM Research Onlineresearchonline.lshtm.ac.uk/2228560/1/2015_EPH_PhD_Oteng...1 Obesity in pregnancy: Epidemiology and development of a lifestyle intervention Eugene Oteng-Ntim Thesis

When Necessity Begets Ingenuity: E-Waste Scavenging as a ...asq.africa.ufl.edu/files/oteng-ababio-2012.pdf · International Labour Organization (ILO) (2002) more than 50 percent of

Case Reports Hemisection: A conservative management of

Spinal Cord Hemisection Facilitates Aromatic L-Amino Acid

STANDARD NEUROLOGICAL CLASSIFICATION OF · PDF fileCLINICAL SYNDROMES-Central Cord Brown-Sequard Anterior Cord Conus Medullaris Cauda Equina ASIA IMPAIRMENT SCALE

Syndrom Brown Sequard

88249023 Syndrom Brown Sequard

Síndrome de brown sequard o hemisección de la medula