EM Forum Case #112 "Not Just Postictal"
by Charlene Babcock Irvin, MD, FACEP  

A 62 y/o patient arrives via EMS with the chief complaint of a ‘fall down the stairs.’ Per EMS, the patient was seen going up the steps, reached about half way up (about 5 steps) then began to have a seizure and fell back onto the floor. He never regained consciousness and EMS was called. He is a member of a group home and suffers from schizophrenia and seizures. No other information is available (he has never been to this hospital) except the group home person there noted he hated to take his Phenytoin (Dilantin) and often they found Phenytoin capsules in his garbage can. Blood pressure at the scene was 110/60, HR=80, RR=14.

I order my usual 6 things for sick people (IV, oxygen, monitor, undress the patient, get me a set of vital signs, and draw some blood), and I ask for blood glucose check as I proceed with my physical exam.

PE: A WDWN (well developed, well nourished) tall man, with a c-collar in place, on a back board with snoring respirations.

VS: BP 105/60, HR=78, RR=16, Sat (on 100% NRB) = 100%. Airway is open, =breaths sounds.

HEENT: PERRL (3mm), mouth is suctioned of a small amount of secretions (gag is present). C-spine immobilized, no obvious step offs on palpation posterior).

HEART: RRR, no Murmurs

LUNGS: Clear bilaterally, breathing is not labored, but is shallow. Poor chest excursion. No subcutaneous air palpated.

Abd: Soft, non-tender. Priapism is noted.

Ext: No obvious fractures or bleeding identified.

Back: No complaints or moans on palpation, rectal tone diminished but present. No gross blood.

Neurologic Exam: Initially, no eye opening (even to pain) =1, random moans (=2), and no motor response to pain at hands or feet. Reflexes absent. He moans slightly to a pinch on the shoulders, otherwise no response to pain.

With these neurologic findings, a spinal injury was suspected. The mental status was also severely abnormal, and a stat glucose was obtained as was a chest X-ray, lateral C-spine, and pelvis X-rays. A stat CT of the Head and Neck and Abdomen was ordered, and thoracic and lumbar radiographs were ordered. FAST was negative.

The portable C-spine radiograph is obtained. See image at this site:  http://www.maitrise-orthop.com/corpusmaitri/orthopaedic/102_duquennoy/fig03-jacquot2.JPG

Questions:

1. What type of fracture is this? Is it stable?
 
2. How often do comatose trauma patients (GCS<9) have a cervical spine injury? What if they have a thoracolumbar fracture? What is the incidence of an associated cervical spine injury?
 
3. Which is better, the NEXUX low-Risk Criteria or the Canadian C-Spine Rule?

4. What is the ASIA score, and what is the maximum score?

5. What is the importance of decreased anal sphincter tone?

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