Management of Spinal Cord Injuries - Case Study Part 1

History of Presenting Condition

John is a 19 year old student, who had an accident while on holidays with his friends, when his head hit a sandbank as he dived into the waves. His friends were experienced first aiders and were first responders to the accident. John hit his head and was floating on the water for approximately 20 seconds, his friends initially thought he was joking around but one friend realised that John was having trouble and went to check on him. He realised there was a problem, called to his other friends to assist with turning John and to call for an ambulance. John was turned face up in the water. He was awake and had a weak cough, he had swallowed some water but was breathing. John was taken out of the water by six individuals, including two lifeguards who arrived on the scene who supported his neck throughout. He was positioned lying on his back, supported at the neck and covered with a blanket to try maintain his body temperature as they waited for assistance to arrive.

Paramedics arrived at the scene within 15 mins. John was lying in the supine position, he reported severe pain in his neck and was unable to move his arms and legs. He was drowsy but, oriented to his current location, and some details of the accident. He complained that he could not feel his arms and legs. His pupils were equal and reactive to light. He showed no other signs of injury but paramedics were concerned as John may have inhaled some water during the accident. His vital signs revealed a blood pressure of 110 / 72, heart rate of 82 beats per minute, respirations of 22 per minute. The paramedics applied a cervical collar, placed him on Ferno Scoop Stretcher, immobilized his head, provided 100% Oxygen and transported him to the trauma center by helicopter. He arrived at the hospital and underwent initial assessment within 120 mins of the accident.

Past Medical History  

Asthma - Exercise Induced

ORIF Left Trimalleolar Fracture 3 years ago 

Social History  

Full time student studying Sociology and English in his first year at University. He is right hand dominant. 

John is a music lover. He plays the guitar. John also plays on the University Hockey Team, and in his spare time enjoys Mountain Biking and Running. He has a part time job at the University Library.

He currently lives in a two storey house with 3 other university students during the University year and spends his University Holidays at home where he lives with his parents, one older brother and two younger sisters. 

Initial Medical Assessment

Vital Signs:

  • Blood Pressure 94 / 55
  • Heart Rate 64
  • Respiratory Rate 32 with shallow breathing
  • Oral Temperature 35.1 Degrees Celcius
  • Color Pale
  • Skin Cold and Clammy to the touch
  • Drowsy

Reflexes:

  • Minimal biceps brachii stretch reflexes, with no triceps or wrist extensor reflexes.
  • All other muscle stretch reflexes in the upper and lower extremities were absent.

Sensation:

  • Perception of sensory stimuli ended bilaterally at an imaginary line drawn across his chest 1/2 inch above the nipples.
  • Some sensation in his arms, but could not localize touch or describe texture with any consistency there.

Strength:

  • Able to elevate his shoulders and isometrically contract his biceps brachii slightly in each arm, but could not raise either arm against gravity.
  • Lower extremities were flaccid, despite attempts to move them

Investigations

X-Rays:

  • Cervical Spine: Unstable C6 Compression Fracture or Axial Loading Injury (Burst Fracture).
  • Chest: Decreased Lung Expansion upon Inhalation, Mild Pulmonary Oedema

CT Spine:

  • C6 Lesion with no Vascular Haemorrhages noted but some blood evident at C5-6 with bone fragments in the Spinal Canal

CT Brain:

  • Mild Frontal Contusion

Blood Gas:

  • Acute Decompensated Respiratory Acidosis with Hypoxemia & Hypercapnia (pH 7.27; PaO2 60 mmHg; PaCO2 70 mmHg; HCO3 25.2 mEq/L; SPO2 89%)

Medical Management

Intensive Care:

  • Stabilise Condition
  • Intubated to Manage Respiratory Function
  • Monitored and Treated for Neurogenic Shock

Surgery:

  • Spinal Fixation at C4 - C8 with Spinal Decompression on Day 2

Drug History

Pre Inury:

  • Nil

Post Injury:

  • Steroids (Methylprednisolone) administered within 3 Hours following Injury over 24 Hours