History: Allen Dexter, a 19-year-old college student, was rock climbing when he
ID: 127371 • Letter: H
Question
History: Allen Dexter, a 19-year-old college student, was rock climbing when he fell 30 feet to the ground. Paramedics arriving at the scene found him lying in the supine position, unable to move any extremities and complaining of neck pain. He was awake, alert, and oriented to his current location, the date and day of the week, and the details of his fall. His responses to questioning were appropriate. 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 except for several scrapes on his arms. His vital signs revealed a blood pressure of 110 / 72, heart rate of 82 beats per minute, respirations of 18 per minute. The paramedics applied a cervical collar, placed him on a back board, immobilized his head, and transported him to the trauma center by helicopter.
Upon examination at the hospital, Allen had minimal biceps brachii stretch reflexes, but no triceps or wrist extensor reflexes. All other muscle stretch reflexes in the upper and lower extremities were absent. His perception of sensory stimuli ended bilaterally at an imaginary line drawn across his chest about 3 inches above the nipples (i.e. everything below felt numb). He had some sensation in his arms, but could not localize touch or describe texture with any consistency there. He was able to raise his shoulders and tighten his biceps brachii slightly in each arm, but could not raise either arm against gravity. His lower extremities were flaccid, despite attempts to move them. Vital signs were taken again at the hospital and were as follows: blood pressure=94 / 55; heart rate=64; respiratory rate=24 (with shallow breathing). His oral temperature was 102.2 degrees F. His color was dusky and his skin was warm and dry to the touch.
X-rays taken upon arrival revealed a fractured vertebra at the C5 level. A chest X-ray showed a decreased lung expansion upon inhalation. Blood tests were normal, with the exception of a respiratory acidosis (blood pH = 7.25). The neurosurgeons immobilized his neck by inserting tongs into the skull above the ears to hold his neck in a position so that no further injury could occur. Allen was transferred to intensive care and his condition was stabilized.
A physical examination four days later revealed normal vital signs and no change in his arm strength or sensation, but also marked spasms and exaggerated stretch reflexes of the lower extremities. He also had urinary incontinence which required the placement of a Foley catheter connected to a urine collection bag.
Can You help me with following:
1. Why did the paramedics apply a cervical collar, place him on a back board and immobilize his head?
2. How would the paramedics test Allen's pupils reaction to light and what would the anticipated normal response be when exposed to light?
3. List his vitals on the scene of the accident and compare them to his vitals at the hospital when he arrived and four days post surgery.
4. What did the x-rays reveal?
5. What did blood tests reveal?
6. Describe the surgical procedure that was performed?
7. What were the physical findings four days post op?
Explanation / Answer
1.Cervical collar is a medical device that is used to give support to a person's neck. In the above condition Allen was found lying in supine position, unable to move his extremities and complaining of neck pain. All these signs point to traumatic neck injury. In such cases there's always a possibility of cervical fracture and risk for spinal cord injury. In such cases if a person performs movement of the neck it may further worsen the situation leading to complete paralysis. Therefore as a preventive measure to stabilise the first seven vertebraes and restrict movement cervical collar was applied by the paramedics and placed on a back board. Immobilization was done to again restrict the movement of head and prevent exacerbation of the problem and possible spinal cord injury.
2.Pupils reaction to light are tested by first examining the overall size, shape and symmetry of pupils. This is followed by making the patient look at a distant object and dilation of pupils. Shining a ray of light into pupil and watching it's constriction. In normal circumstances they react briskly to light.
3.
110/72
(BP)
94/55
(BP)
Normal
(BP)
82 beats/minute
(heart rate)
64 beats/minute
(heart rate)
Normal
(heart rate)
18 breaths/minute
(respiratory rate)
24 breaths/minute
(respiratory rate)
Normal
(respiratory rate)
4.His X rays revealed a fractured vertebra at C5 level. Another chest x ray was also taken which showed reduced lung expansion on inhalation.
5. The blood tests revealed respiratory acidosis as the pH of blood was 7.25.Rest of the results for blood tests were normal.
6.Neurosurgeons performed the surgery for immobilization of neck. This was done by inserting tongs into the skull right above the ears. This way the neck would be held in a position and no further injury could occur.
7.Normal vital signs were seen four days post op. Arm strength and sensation were as before that is some sensation present at the arms but inability to localised touch. Ability to raise shoulder but not against gravity. Lower extremities has spasms and exaggerated stretch reflexes.
Comparison between the vitals signs the site of the accident to the vitals in the hospital and four days post op. At the site of the accident (vitals) At the hospital (vitals) Four days post op (vitals)110/72
(BP)
94/55
(BP)
Normal
(BP)
82 beats/minute
(heart rate)
64 beats/minute
(heart rate)
Normal
(heart rate)
18 breaths/minute
(respiratory rate)
24 breaths/minute
(respiratory rate)
Normal
(respiratory rate)
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