You see an 8 year-old girl on D-Side with PMH of a neonatal stroke, resolved seizures and a closed VSD who was doing headstands at home when her arms gave way and she fell on her head. No LOC, numbness, tingling, or vomiting. Her mental status is normal but she reports midline neck pain and a headache.
Meds: None
Family Hx: Hypertension
PE:
VS: T 36.5, HR 73, RR 24, BP 98/61, O2 sat 100% RA, Wt 23kg
Well appearing, wearing a Miami J C-collar, NAD
Neuro exam is unremarkable. Gait not tested because patient is immobilized.
Physical exam is only notable for midline tenderness around C1-C2 with no bony step offs. No scalp hematoma.
You order cervical spine x-rays given her midline cervical tenderness and they are negative. She still reports midline tenderness in the same location despite Motrin so you proceed with a focused CT of her cervical spine.
You continue to see other patients when radiology calls to say that the CT shows a type I dens fracture.
Three questions for you (hit "vote" to see what others said):
The nurse calls you into the room because the patient's heart rate is in the 40s on the monitor. The patient is warm and well perfused in NAD. You order a stat EKG and find the following:
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Whoa. I'm stumped. I can't believe she fractured her dens. What else is wrong with her? Is the stroke supposed to make me think of something in particular? That Lauren Staple is kinda sneaky... (:))
ReplyDeleteHmmm... this does remind me of that one kid several years ago who was 8 or 9 and had trisomy 21 and had a weird gait and came into the middle bed of those 3 bed rooms, got a once over from an associate and got sent home and had a C1-C2 subluxation that was found later and ended up in that giant helmet-collar thingy...
Now off to tell Sabine no more headstands...
Hi all. I was the nurse, she actually was my patient. I wondered if she had syncope ??
ReplyDeleteMakes it sorta fun when they brady, right? then you wonder if they're concussed, have intracranial process, cardiac contusion, or underlying cardiac/metabolic disease.
ReplyDeleteI like to call the trauma senior/fellow on these. You've already evaluated head-to-toe and stabilized so no reason to call a trauma stat here. But you DO need to do a real neuro exam to evaluate for signs of SCI. if no actual neuro deficits, GCS=15, and she has normal perfusion/pressure....then put her in room 18 supine in a collar. No spinal emergency at the moment. Trauam surgery can coordinate with ortho and neurosurg and save you time so you can go see 300 other patients with the flu. If i made one phone call it would be to PICU, because i don't think she's immediately surgical and i don't think the floor would be able to handle her with HR's in the 40s. trauma service and telemetry never works so good :)
I would do a non-con head and neck CT, both to evaluate for ICI and for extension and further delineation of the fracture (and to validate it.....). For her 2nd degree AV block, probably a good idea to do a CXR, lytes, a medical hx, and get cards involved.
Look at your watch and give yourself 2 hrs to have her physicall out of your ED unless she has some more serious event or starts showing signs of SCI.
I love all of the commentary, as it was definitely a challenging case! Keep the replies coming! Happy holidays everyone from our lovely ED! :)
ReplyDeletespecial thanks to fellow Lauren, for such a fast response and also taking such an appropriate steps in timely manner for a kid at such a young age and seriouis condition. It was a pleasure working with you.
ReplyDeleteThis patient has dens fracture, drop in HR 73--->44, well perfused is in spinal shock (neurogenic shock). His BP if not low now will turn for the worse keeping him well perfused. He needs IV bolus and likey norepinephrine drip, transfer to neurosurgical ICU or PICU.
ReplyDeleteHe needs to be brought to Trauma room and trauma activated taking all cervical spine precaution
Intense case! Great discussion.
ReplyDeleteBiggest concern here is acute spinal shock and possible paralysis.
She needs to complete a detailed physical with the trauma team in the trauma room with frequent vitals, ETC02 monitoring. Good perfusion still needs a good blood pressure as hypotension in these cases leads to worse outcome from hypoperfusion of spinal cord. Would consider starting atropine to treat the unopposed vagal tone. If hypotensive, I've seen n/surg use norepinephrine (or dopamine) although I don't think there is any great evidence of which pressors to use here (just not a pure alpha like phenylephrine).
Definitely PICU for frequent vitals, neuro checks.
Consider head CT and upper thoracic CT to r/o further ICI and spinal fractures. If intubation, would call anesthesia to assist over my R shoulder and take over if unable to secure without moving neck.
i kinda disagree with the above.
ReplyDeleteFirst of all, spinal shock is different than neurogenic shock.
It's hard to get spinal shock without injury to the spinal cord. and if there is SCI, you should see neurologic signs such as hyporeflexia, sensory level, parasthesias, motor deficit, etc. This is why your NEURO exam is so important here and you don't need a trauma intern to do it for you.
Now you can get neurogenic shock with spinal injury from unopposed parasympathetic (depressed sympathetic) tone. This only occurs in upper spinal lesions and manifests as hypothermia, hypotension, and bradycardia. But the bradycardia here should be sinus (i would think) and this kid has some missed QRS's. I think of neurogenic shock as a progression from spinal shock, so again it's hard to get to this point if you don't have neuro deficits. At some point i wrote a review article on SCI, although have NEVER seen a case of SCI neurogenic shock myself so i'm hardly an expert! But they say you can get to the neurogenic shock phase with fracture and no SCI.....but it implies large hemorrhage into the space and should manifest as hypotension/vasodilation.
again: neuro exam, perfusion, pressure. important
agree with Paul, if there are signs of progression to neurogenic shock, atropine and norepinephrine or phenylephrine are the way to go.
interesting case!
I am very intrigued (and puzzled) by the case. A dens fracture is a high spinal cord injury and if is unstable or if it damages the spinal cord at that location should lead to flaccid paralysis (or focal weakness and hyporeflexia in some, if not all the extremities)... but we have a normal neuro exam! As for the bradycardia, it's not just sinus bradycardia that one would expect to see with unopposed vagal tone, but is 2nd degree heart block which I have never heard being associated with head or spine injury (which doesn't necessarily mean they can't be linked). Is this a situation of "true, true and unrelated"? Maybe the two findings (c-spine injury and 2nd degree heart block) are not related. Regardless I would keep a super close eye on the BPs and HR, frequent neuro exams looking for progression to flaccid paralysis or other signs of spinal shock. PICU notified for close monitoring, Cards notified for the 2nd degree heart block. And an Internet search for " c-spine injury and heart block"!
ReplyDeleteHappy Holidays to all! Great case Lauren. -Jamil
Hot Seat Response by Mohsen Saidinejad, MD
ReplyDeleteThanks Lauren, for an interesting and challenging case, and thanks to all others who posted responses.
This is an 8 year-old female who suffered a neck injury after losing her balance while doing head stands. The tenderness over the C1-C2 spine and the CT finding of a type I dens fracture suggest neck hyperflexion as the mechanism of this injury. She complains of a headache, but her exam is otherwise unremarkable. Additional information includes bradycardia to 40s on the monitor during her ED course.
Type 1 dens fracture (fracture through the superior aspect or tip of the dens), is the least unstable, but it can still be associated with significant ligamentous injury. I am not completely sure about what to make of the resolved neonatal issues as they relate to this case. In my opinion, the heart block is likely unrelated to the injury.
Differential diagnosis for the bradycardia:
Traumatic brain injury with possible uncal herniation with c-spine injury: This may be considered given the headache (concussion?) and progression to bradycardia. The patient, however, is not displaying the hypertension and irregular respiration. The otherwise normal exam, the lack of LOC history, and the normal mental status, also makes this not entirely likely.
Simple vasovagal syncope versus seizure activity preceding the neck injury: This is always on the differential, and may also be related to her heart block.
Neurogenic shock: Given the mechanism of injury, disruption of the spinal cord anatomical pathways may be a consideration, especially if the atlanto-axial ligamentous injury is suspected. Bradycardia, secondary to unopposed vagal tone, and subsequent hypotension, related to decreased systemic vascular resistance and pooling of blood in the extremities. May be a progression of this. With a type I dens fracture, the spinal cord disruption is generally expected to be less.
Spinal shock: This type of non-circulatory shock is less likely, again, given the nature of the dens fracture, which makes a transection of the cord less likely. It should be considered in the differential diagnosis, however, given the neck hyperflexion severe enough to cause a dens fracture. I don’t think this patient is in spinal shock, given lack of any sensory or motor deficits. Also, the type I dens fracture makes a complete spinal cord injury, leading to spinal shock less likely.
A primary cardiac etiology unrelated to the neck injury: Given the second degree heart block (Mobitz type1, a.k.a. Wenckebach), some sort of traumatic cardiac injury versus undetected baseline heart block should be considered as well.
Management:
This patient has a serious traumatic injury mechanism, and should be considered at risk for further neurologic deterioration. In terms of what to do next, I don’t think we need to get a trauma alert called, but given our resources and challenges in coordinating various sub-specialties (Trauma surgery, orthopedics, and neurosurgery), I would ask for a trauma alert anyway. Atropine can be a treatment option for heart block and bradycardia from neurogenic shock. I am not quite ready for atropine, because of the good circulatory status. If BP starts dropping more, dopamine or norepinephrine is on my agenda.
So, this is what I would do: (very frequent monitoring of vitals)
- Trauma alert now in the ED. (With PICU)
- Rigid collar
- Bring patient to the code bay.
- Full CR monitor, and have trauma evaluation.
- Detailed neurologic exam
- Neurosurgery and orthopedics (Dens fracture), CICU consult for heart block
- Move this patient to PICU ASAP. I don’t think I need to intubate or start atropine right now, but these are both something I need to consider later.
- I would do a non-contrast head CT
- Basic trauma labs including a CBC.
- I would love to have an MRI of the c-spine when possible
Wow-this is crazy. My first instinct would be that she does not need to be a trauma stat, but if nursing/staffing were issues then I don't think it would be unreasonable. Definitely get neurosurg involved asap. She has bradycardia, but if it was from vagal tone or the injury itself I would expect it to be sinus brady, not dropped QRS's with regular P waves. So no atropine right away. I would also do a head CT, but would want the PICU and/or neurosurg involved just in case she did something crazy in the scanner- they might get a bit annoyed if we sent a kid with a dens fx & bradycardia into the scanner & they didn't know about her. (right?!?) Can't wait to see the punch line!
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