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Trauma question

Discussion in 'Emergency Medicine' started by jbod34, Aug 1, 2006.

  1. jbod34

    jbod34 Member
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    This is a USMLE world Board question (Hopefully I'm not breaking any laws by repeating the question!!)
    Lady comes in with epistaxis and open tib/fib fx after jumping from a three story building. She is unconscious on arrival. Pupils are bilaterally equal and reactive. Responds to pain with eye opening and is able to move all limbs. Next step in her management?
    CT head
    XR Neck
    XR Leg
    LP
    XR Head

    Now the answer was XR Neck to RO C spine fx. Why would you not want to RO intracranial path with a head CT first. The C spine isn't going to change while pt is in c collar and inline stabilazation is maintained. Any clues or am I missing something?
    Thanks
     
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  3. DropkickMurphy

    DropkickMurphy Membership Revoked
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    I believe the reason that's the "correct" answer is because the x-rays are much quicker than the CT and you can get them out of the way.
     
  4. leviathan

    leviathan Drinking from the hydrant
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    No training in ATLS here, but my own first guess would have been CT head. As you said, a c-spine # is not going to be life threatening in itself, at least not before an intracranial hemorrhage or other injury would be. Of course in reality, I guess it doesn't take long to shoot an x-ray at the neck and then continue on, but going strictly by what should be done first, head CT sounds more important. But I guess they are the experts.
     
  5. Seaglass

    Seaglass Quantum Member
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    Yeah, head CT
     
  6. bulgethetwine

    bulgethetwine Membership Revoked
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    I think this is probably becase triple trauma plain films -- in the resus bay -- typically come before head CT.

    But I can see the confusion due to "common sense" concerns.
     
  7. st0rmin

    st0rmin Unregistered User
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    In ATLS, and with most board questions, you should approach them thinking that you are the sole provider in a rural ED with little or no support staff. You may not have a CT readily available, but most places will have a portable x-ray with someone who knows how to work it. Just my .02
     
  8. EctopicFetus

    EctopicFetus Keeping it funky enough
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    Exactly.. and as someone who recently completed ATLS this is the key. Obviously at any place you train at you will have a CT scanner... but if you are in bumble-f you can get the films of the neck easily..
     
  9. BKN

    BKN Senior Member
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    The correct answer isn't there - RSI and sedate to protect airway. After that the answer should be CXR and Pelvis film, then CT head. The question is old and reflects practice in the late 80s and 90s. In the 70s and 80s, the practice was to do a trauma panel (CXR, Pelvis and Lat Cspine). Thought was that stuff on the first two could tell you about reasons for death in the next few minutes and that everyone needed c spine cleared prior to intubation. In the 90s, easier and faster CTs made the trip to the scanner less scary and orotracheal intubation with in line traction was demonstrated to be safe. Now its not clear that you need the cspine films at all, given that many centers would CT the neck along with the CT head.

    Unfortunately, thats true of many questions in any kind of medical test. On average, the best students and docs should get the best scores, but there's a price for being up to date.
     
  10. southerndoc

    southerndoc life is good
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    Yea, what BKN said!
     
  11. Jeff698

    Jeff698 EM/EMS nerd
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    The other reason I don't like CS XR is that, in my experience, they aren't all that fast. Especially in trauma patients (and God help you if they're fat) you get plain films thinking it'll be fast and you can't see crap. What do you do?

    Spin their neck.

    Why not do it all at once with the head and just be done with it. It's not like you're not gonna spin this patient's head after their initial presentation.

    Take care,
    Jeff

    PS, yes, I know I'm spoiled.
     
  12. BKN

    BKN Senior Member
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    Yes, you are but you're not wrong.

    At least one reason to keep getting the films, even when you know you're gonna spin the neck is to keep in practice reading them. The majors are ones most likely to have findings for you to spot. Then when you're doing low probability films, you can read them.

    Unless you want to spin every 20 yo with a minor whiplash?
     
  13. SoCuteMD

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    Is it bad that I often peek at a thread, and then come back to find out the "answer" when I see that BKN has posted. :p
     
  14. GeneralVeers

    GeneralVeers Globus Hystericus
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    In my opinion XR of the C-spine wouldn't be my first choice. The patient is in C-collar, so it would be difficult to get an adequate study with the collar in place.

    Since you are going to scan the head, just scan the C-spine while you're at it.
     
  15. leviathan

    leviathan Drinking from the hydrant
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    Yeah, based on the difficulties of sometimes getting a good x-ray film, why not just throw 'em in the CT and do both head and neck at the same time? I think this original question has way too many assumptions behind it that they don't elucidate for you.
     
  16. kbrown

    kbrown chicken
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    I had this question last year, and if I remember correctly, the reason for the question was "mechanism of injury". They wanted you 1) to acknowledge how to treat pts in rural america and 2) to realize the distribution of force/injury. I think the explanation that I remember was something to the effect of, "pt jumps from real high, breaks legs, energy transmitted to spine could lead to fracture". not necessarily C-Spine, but nonetheless.

    Most places have x-ray immediately available, some have portable right there and some are fortunate enough to have x-ray overhead in trauma bays (unreal). but regardless, these standardized test-trauma questions are not geared toward em residencies with level1/2 status, all the bells and whistles locations. Rather they are geared to Dr Sam Smith DVM (vet medicine) in po-dunk america with only an x-ray machine. (already been said)
     

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