see also: [[Cervical spine trauma radiology]] , [[Thoracic and lumbar trauma radiology]], [[SCIWORA]], [[Airway#neck trauma airway]], [[carotid and vertebral artery dissection]], [[Denver|Denver criteria]]
[[paediatric c-spine]]
bear: [Jenny's talk](bear://x-callback-url/open-note?id=48FCFD04-9862-4D84-82AC-A53D7CCDAE52-22499-00000B8841D06A49)
links: [CanadiEM guide to spinal cord syndromes](https://canadiem.org/a-boring-guide-to-spinal-cord-syndromes/), [Rosen Spinal cord disorders](x-devonthink-item://E503214B-122B-434B-87D4-F04631F3A011)
[Dunn - penetrating neck trauma](x-devonthink-item://0F8FCCB8-7CC7-4B82-97BE-1A16E79A074F), [Dunn - Laryngotracheal trauma](x-devonthink-item://E843E991-371F-4AFC-8B09-819F8DF5DE63), [Dunn - cervical spine fractures](x-devonthink-item://E3A95078-8472-4BA0-870F-7422F8E741CE), [Dunn - Cervical spine injuries](x-devonthink-item://EC4F0647-6A4D-4C50-9126-94B12E809798)
[tintinalli - trauma to the neck](x-devonthink-item://1ADC8D20-7826-44D0-9DEE-31D41057C9A3?page=53)
> [!Key Points]
> - keep **MAP ~85** for neurogenic shock, fluids + vasopressors (and treat for haemorrhagic shock)
> - penetrating neck injury are significant if injury has penetrated through the platysma
> - [[Denver]] criteria for blunt cerebrovascular injury
> - **neurogenic shock** - loss of sympathetic tone after spinal cord injury above level of T5 causing *vasodilation*, *hypotension*, and *bradycardia*
> - **spinal shock** - "bruise" or "concussion of spinal cord", often secondary to localised oedema, can be *reversable*. A/w *flacid areflexia* after spinal injury, priaprism may be present, also motor/sensory deficits
![[Pasted image 20230422123701.png]]
# Unstable Fractures
see also: [[Cervical spine trauma radiology#Unstable C-spine fractures]]
#tables
*mnemonic:* **Jefferson Bit Off A Hangman's Toenail**
| fracture | description | pic |
| ----------------------------------------------------------------------------------------------------------------------- | ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ | ------------------------------------ |
| [[Cervical spine trauma radiology#Jefferson's fracture (C1 burst fracture)\|Jefferson fracture (c1 burst)]] | due to axial load | ![[Pasted image 20230531144541.png]] |
| [[Cervical spine trauma radiology#bilateral facet displacement\| Bilateral facet displacement]] | significant ligamentous instability<br><br>**note**; not always facet, can also just have anterolisthesis / dislocation or fracture-dislocation | ![[Pasted image 20230430210938.png]] |
| [[Cervical spine trauma radiology#odontoid peg fracture\|Odontoid Peg]] | type 1 tip (stable), type 2 neck, type 3 body | ![[Pasted image 20230428213852.png]] |
| Atlanto-axial dissociation | unstable "internal decapitation", lateral widening of C1-C2 and predental space, poor outcome | ![[Pasted image 20230531145458.png]] |
| [[Cervical spine trauma radiology#hangman's fracture (bilateral pedicle C2\|Hangman’s fracture (bilateral C2 Pedicle)]] | Hyperextension injury 2/2 abrupt deceleration. At risk for C2 anterior subluxation, C2-C3 disc rupture, and disruption of the posterior longitudinal ligament. cord injury is rare because C2 anterior subluxation widens the spinal canal | ![[Pasted image 20230531145754.png]] |
| [[Cervical spine trauma radiology#Teardrop fractures\|Teardrop fractures]] | very unstable, esp hyperflexion. SIGNIFICANT ligamentous injury. Common neurologic spinal injury, especially [[#anterior cord]] | ![[Pasted image 20230429211320.png]] |
# Clinical rules
see also: [[Cervical spine trauma radiology#literature on c-spine clearance]]
[ACEM 2020.1 OSCE - clinical C-spine clearance](x-devonthink-item://AC20DBBE-38CB-4DB0-8B26-FFC42D949D47)
> [!pearl]- Should we "use" NEXUS or Canadian C-spine?
> Dr. Jerome Hoffman, the author of NEXUS, has this to say:
> - "NEXUS is not something you have to think seriously about – it’s based on what you already know. It allows you to do what you know is right in a patient whose risk is minimal by your assessment."
> - "Don’t apply the NEXUS rule if you’re truly worried a patient might have a fracture. You don’t have to do films even if they’re “clear” by NEXUS. *NEXUS doesn’t tell you when you have to image, it tells you when you’re allowed to not image.*"
> - "It’s purposefully vague (no definition of intoxication by alcohol level, no definition of distracting injury), because it’s meant to be used by a physician with good clinical judgment and gestalt. If you think they’re intoxicated, they’re intoxicated. If you think they’re distracted, they’re distracted."
> - "Some people should probably go straight to CT:
> - The elderly
> - multi-trauma patients
> - very high pre-test probability patients"
>
> My take is that if we are clinically assessing a patient for C-spine injury, there is value in considering both tools. Is someone going to make a decision about whether or not to start antibiotics for a possible chest infection based only 5 criteria designed to avoid unnecessary antibiotics without considering other salient historical details about the patient? So the other historical features, some of which happen to be well-covered in Canadian C-spine, seem relevant to our overall assessment of the patient with possible C-spine injury. As Dr. Hoffman himself notes, patients with high pre-test probability should likely go straight to CT.
## Nexus
> unlike Canadian C-spine, no specific age cut off, age 1-101. However, caution in patients > 65, sensitivity ↓ ([Paykin et al 2017](https://www.ncbi.nlm.nih.gov/pubmed/28274471)) ~ 94.8%. Also, mechanism not taken into account
- no midline cervical tenderness
- no intoxication
- normal alertness
- no focal deficit
- no painful distracting injury
If none present, then likely imaging not required
## Canadian c-spine rule
> age ≥ 16 to 65
> more sensitive than NEXUS
***1. Image if high risk feature:***
dangerous mechanism (fall >3 ft or 5 stairs, axial load to head, high speed MVA >100km/h, ejection from vehicle, bike accident, moto recreational accident), age > 65, extremity parasthesia
***2. If not high risk, are low risk features present?***
sitting in ED, ambulatory at any time, delayed neck pain, no midline tenderness, simple rear-end MVC
***3. If a low risk factor is present:***
If able to actively rotate 45 deg L and right, then cleared via Canadian C-spine rule
# Thoracic fractures
- more common in elderly
- red flags: fall from height, axial load, lap belt injuries, neuro deficit
- if find one fracture, look for another
## Anterior vertebral compression fracture (wedge)
- stable if <50% loss of vertebral height
- ==unstable if >50% loss of vertebral height==
## Chance fracture
- usually T12-L2
- horizontal fracture through vertebrae
- associated with lap belts and abdominal injuries
## Burst fracture
vertebral compression --> bone retropulsion into canal
if no reropulsion or neuro findings, likely analgesia no surgery
![[Pasted image 20230531152051.png]]
# Spinal Cord Injury
see also: [[Cervical spine trauma radiology#Spinal cord syndromes]]
![[Pasted image 20230430214245.png]]
![[Pasted image 20230430214449.png]]
**Corticospinal tract** has upper motor neuron -- tends to have more spastic syndromes
**Anterior horn** has lower motor neurons -- more flacid paralysis
![[Pasted image 20230616124317.png]]
![[Pasted image 20230531152714.png]]
## Exam
See also [[Neuro - upper limb]] and [[Neuro - lower limb]]
[Rosen - spinal cord injury exam](x-devonthink-item://949DFB87-DEB3-4BE2-818D-21D2B115168D?page=16)
### Spinal Motor Examination
| Level of Lesion | Resulting Loss of function |
| --------------- | ------------------------------------------------------------------------ |
| C4 | Spontaneous breathing |
| C5 | shrugging of shoulders |
| C6 | Flexion at elbow |
| C7 | Extension at elbow |
| C8 - T1 | Flexion of fingers |
| T1 - T12 | Intercostal and abdo muscles<br>(localise lesions with *sensory* levels) |
| L1 - L2 | flexion at hip |
| L3 | ADduction at hip |
| L4 | ABduction at hip |
| L5 | dorsiflexion of foot |
| S1 - S2 | plantar flexion of foot |
| S2 - S4 | rectal sphincter tone |
### Spinal Sensory Exam
> localisation of T1 - T12 injuries best done with sensory level on [[Dermatomes]] chart or per table below
| Level of lesion | Resulting level of loss of sensation |
| --------------- | ------------------------------------ |
| C2 | Occiput |
| C3 | thyroid cartilage |
| C4 | suprasternal notch |
| C5 | below clavicle |
| C6 | thumb |
| C7 | index / middle finger |
| C8 | small finger |
| T4 | nipple line |
| T10 | umbilicus |
| L1 | femoral ulse |
| L2 - L3 | medial aspect of thigh |
| L4 | knee |
| L5 | lateral aspect of calf |
| S1 | latearl aspect of foot |
| S2 - S4 | perianal region |
## Central cord
- classically elderly patients
- more upper-extremity than lower extremity
- can also be associated with **extension teardrop fracture**
## anterior cord
- region supplied by anterior spinal artery is damaged
- motor loss and paralysis below level of injury
- spinothalamic impaired; analgesia and loss of temperature and course touch
- dorsal colums intact; preseveration of joint position, vibration sense, and fine touch
- often due to flexion-rotation or vertical compression injuries
## posterior cord
## Brown-sequard
- unilateral symptoms, contralateral loss of pain and temperature
| | motor | pain/temp | proprioception/light touch |
|:-------------------|:--------------------------|:--------------------------|:--------------------------|
| brown-sequard | ipsilateral loss | contralateral loss | ipsilateral loss |
| anterior cord | loss below injury | loss below injury | preserved |
| central cord | upper loss > lower loss | upper loss > lower loss | preserved |
## Spinal shock / spinal "stun"
- not really shock; nothing to do with circulatory system
- it is a spinal stun, a contusion of the spinal cord
- below level of injury: loss of sensation + motor function, loss of reflexes
- may last hours to several weeks
bulbar-cavernosus reflex is what signifies the end of "spinal shock" (squeezing glands of penis), rectal tone
# neurogenic shock vs. spinal shock
**neurogenic shock** - loss of sympathetic tone after spinal cord injury above level of T5 causing *vasodilation*, *hypotension*, and *bradycardia* . low systemic vascular resistance, ↑ parasympathetic activity, and bradycardia.
**spinal shock** - "bruise" or "concussion of spinal cord", often secondary to localised oedema, can be *reversable*.
- *flacid areflexia* after spinal injury
- priaprism may be present, also motor/sensory deficits
- less shock
- not a true form of shock because no circulatory collapse
- resolves as soft tissue injury improves, hours to weeks
# Penetrating neck injury
See: [coreEM - penetrating neck injury](https://coreem.net/core/penetrating-neck-injuries/), [Rosen - Nexk trauma](x-devonthink-item://5DCF761E-A0CF-4A7F-A505-378E88BA5185?page=2)
See also: [[Denver|Denver criteria blunt cerebrovascular injury]]
HARD SINS
- Haematoma rapidly expanding
- Arterial bleed
- roaring bruit
- deficits (neurological c/w stroke)
- stridor
- ischemia
- no radial or weak pulse
- shock not responding to fluid
soft signs:
Haemoptysis, haematemesis
Oropharyngeal blood
Dyspnoea, Dysphonia, dysphagia
SC emphysema
ICC air leak
Non expanding haematoma
Focal neurologic deficits
>**Indications for intubation:**
>- stridor
>- acute respiratory distress
>- airway obstruction from blood or secretions
>- ALOC
>- tracheal shift
>- extensive s/c emphysema
>- expanding neck haematoma
>- profound shock
![[Pasted image 20241005162141.jpg]]
## Zones of the neck
| neck Zone | landmarks | structures at risk | investigation modality |
| --------- | ----------------------------------------------- | ----------------------------------------------------------------------------------------------------------------------------- | --------------------------------------------------- |
| I | sternalclavicular joints to cricoid | lung apices, trachea, vertebral arteries, proximal common carotid, thyroid, thoracic duct, spinal cord, cerbical nerve trunks | - angiography<br>- bronchoscopy<br>- oesophagoscopy |
| II | inferior margin of cricoid to angle of mandible | jugular veins, carotid and vertebral arteries, trachea, oesophagus, larynx, spinal cord | operative exploration |
| III | angle of mandible to base of skull | pharynx, jugular veins, parotid, cervical spine, internal carotid, CN IX-XII, | - angiography<br>- bronchoscopy<br>- oesophagoscopy |
![[Pasted image 20230531153639.png]]
# Cerebrovascular trauma
see also: [[Blunt laryngeal injury]], [[Denver]], [[carotid and vertebral artery dissection]]
[Dunn - Cerebrovascular trauma](x-devonthink-item://4D862BD8-5BBD-49CB-BE01-AD0C3154D2E5)
- carotid dissection more common with penetrating than blunt trauma
- blunt trauma more likely to cause neurological deficits due to dissection and false aneurysm formation
- 50% common carotid
- 50% internal carotid as it enters the skull
- sometimes from relatively minor trauma; cervical manipulation ↑ risk
- in blunt trauma, vertebral artery injury usually follows fractures of foramen transversarium of the cervical spine or due to a direct blow compressing the artery against the lateral aspect of C1
- [[vertigo#head trauma|post-traumatic vertigo]] rarely caused by vertebral dissection in the absence of [[#Indications for CT angio|risk factors]]
***Complications***
- external haemorrhage
- false aneurysm formation and vessel occlusion
- AV fistulae
***History***
- neuro deficits (often absent or not recognised initially)
- average time to onset after dissection is ~2-3 days
- [[pupil exam#Horner Syndrome|Horner's syndrome]] ~10% of cases
- bruit or thrill
## Indications for CT angio
- ↓ pulse (rare in blunt trauma or spontaneous dissection)
- cervical haematoma
- horner's syndrome
- cervical bruit or thrill
- localising neuro findings or evidence of infarct on CT
- high risk fractures:
- in region of foramen lacerum
- of the foramen magnum
- [[Facial trauma radiology#Le Fort 2|Le fort 2]] or 3 facial injuries
- of the foramen transversarium
- displaced cervical fractures
## Management of cerebrovascular trauma
- degree of occlusion correlates with likelihood of cerebral infarction for carotid injuries, **but not** for vertebral injuries
| grade | findings | management |
| ----- | -------------------------------------------------------------------------------------------------------------------------------------------------------- | ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- |
| I | - luminal irregularity of dissection with <25% luminal narrowing<br>- usually stable<br>- usually heal by 10 days | - anticoagulants/antiplatlet agents can be ceased |
| II | - dissection or intramural haematoma with > 25% luminal narrowing, intraluminal thrombus, or raised intimal flap<br>- neuro deficits usually progressive | - generally anticoagulation with heparin 15 units/kg/hour (no bolus) followed by warfarin<br>- follow with DAPT when patient stable<br>- aspirin equally effective as heparin/warfarin in patients without major trauma |
| III | - pseudoaneurysm | - anticoagulation<br>- consider stenting |
| IV | - occlusion | - anticoagulation<br>- consider stenting |
| V | - transection with free extravasation | - requires emergency operative repair or stenting if still alive |
# Related Questions
## analgesia
- [ ] 1Q: [Two year old not weight bearing](x-devonthink-item://4BE7EDE1-1843-4BA0-B8D2-0DCEF50784D4?page=7) -- [Answer](x-devonthink-item://15F8F701-8EC8-4F9A-8DEC-5220C8561C8A?page=6) -- [prop](x-devonthink-item://281EC7A9-8E5A-461A-AA34-3FF490AA0EC2?page=5)
- [ ] 2Q: [Rib Fractures](x-devonthink-item://EE0B8625-5F19-46CF-8208-56D79DC48BC5?page=5) -- [Answer](x-devonthink-item://6F751245-A36C-447A-8AE7-599AD5871C71?page=11)
- [ ] 3Q: [Forearm Injury](x-devonthink-item://09CFA1A7-00F1-4151-979E-8F3984924D54?page=47) -- [Answer](x-devonthink-item://CF5E9C2B-42F9-4F9C-AC29-877E20134927?page=30)
## ards
- [ ] 4Q: [Respiratory Failure](x-devonthink-item://B74AA648-7583-42CC-9AC9-1FDBD09A2750?page=10) -- [Answer](x-devonthink-item://2088AEED-9FCF-4CF0-B58D-E4279D4BCC76?page=12) -- [prop](x-devonthink-item://5F365535-E019-4C8D-8402-2E764B328988?page=4)
## cord syndromes
- [ ] 5Q: [Elderly patient with Neck Injury](x-devonthink-item://2CAEF14B-356F-45F8-834C-4766A58A56A9?page=2) -- [Answer](x-devonthink-item://98D17FA0-225B-4E94-B21C-4E36D5C76A7C?page=0) -- [prop](x-devonthink-item://093F49C6-2E32-460E-9C00-3E9F15CD417E?page=2)
## ct
- [x] 6Q: [Flank pain](x-devonthink-item://8A1FC024-FD4E-4202-A93D-77C4E8234DC5?page=4) -- [Answer](x-devonthink-item://7EEBE66F-C2B1-4EF7-B29C-FB52D469C8CD?page=3)
## dic
- [ ] 7Q: [Thrombocytopenia](x-devonthink-item://1A14F7A1-E434-47A6-BC68-AF2DD1A7C090?page=1) -- [Answer](x-devonthink-item://736EC9CD-AC9C-4588-BA1E-F4AD190CBA47?page=25)
## fall
- [ ] 8Q: [Elderly Collapse](x-devonthink-item://F0498813-9350-484C-AD5B-6FF7C3AE9015?page=50) -- [Answer](x-devonthink-item://A491A3F6-FD6D-492F-BCBE-7F7BAE101EDF?page=54)
- [ ] 9Q: [Complex Elderly Presentation](x-devonthink-item://CA4D5561-277D-47A1-9EC2-E0DB4C59DCFD?page=6) -- [Answer](x-devonthink-item://2551B51B-0E7C-448E-9FB5-3B547E74974A?page=6)
## fall from height
- [ ] 10Q: [Ankle injury](x-devonthink-item://F0498813-9350-484C-AD5B-6FF7C3AE9015?page=51) -- [Answer](x-devonthink-item://A491A3F6-FD6D-492F-BCBE-7F7BAE101EDF?page=55)
## fractures
- [ ] 11Q: [Leg Injury](x-devonthink-item://C88FD92C-E0CB-48A1-8D73-F20489FA4E6C?page=13) -- [Answer](x-devonthink-item://98D17FA0-225B-4E94-B21C-4E36D5C76A7C?page=38) -- [prop](x-devonthink-item://093F49C6-2E32-460E-9C00-3E9F15CD417E?page=14)
## imaging
- [ ] 12Q: [Imaging in trauma](x-devonthink-item://2F267333-5FEC-47E5-83D1-CC05B23EB91A?page=9) -- [Answer](x-devonthink-item://C6CAC39D-CAE8-4F76-9C45-689A0464D936?page=6) -- [prop](x-devonthink-item://C5EFC1EA-802B-49BC-824D-CFF7C6FFDBD8?page=3)
## nai
- [x] DUPLICATE Q: [Two year old not weight bearing](x-devonthink-item://4BE7EDE1-1843-4BA0-B8D2-0DCEF50784D4?page=7) -- [Answer](x-devonthink-item://15F8F701-8EC8-4F9A-8DEC-5220C8561C8A?page=6)
- [ ] 13Q: [Humerus fracture in 10 Month Old](x-devonthink-item://D466AD93-18B7-467C-BB6E-192EEBE26935?page=13) -- [Answer](x-devonthink-item://6F751245-A36C-447A-8AE7-599AD5871C71?page=5) -- [prop](x-devonthink-item://308BBEF4-A83E-4972-8F63-9249898FC8E8?page=4)
## neck injury
- [ ] 14Q: [Head and Neck Injury](x-devonthink-item://7FCD3940-4BB4-45FE-86A6-E5707E82D5B5?page=75) -- [Answer](x-devonthink-item://3263A68A-96A6-43EC-985B-43260C3509BF?page=28)
- [ ] 15Q: [Neck Injury](x-devonthink-item://FE3157C2-07B3-43F2-9ECE-AFACE1355E13?page=10) -- [Answer](x-devonthink-item://DDC959EB-0C1E-448A-8380-C397BF734322?page=4) -- [prop](x-devonthink-item://4042F313-756E-469B-BB0C-4CD9D1E5225F?page=1)
- [x] 16Q: [Neck Injury](x-devonthink-item://D466AD93-18B7-467C-BB6E-192EEBE26935?page=2) -- [Answer](x-devonthink-item://6F751245-A36C-447A-8AE7-599AD5871C71?page=1) -- [prop](x-devonthink-item://308BBEF4-A83E-4972-8F63-9249898FC8E8?page=2)
- [ ] 17Q: [Spinal Cord Injury](x-devonthink-item://7061D1B4-0AB9-4963-B3B0-23BDD975B2CD?page=4) -- [Answer](x-devonthink-item://3F30C77E-E23E-4200-89FE-48A41618E0C2?page=3)
- [ ] 18Q: [Neck Injury](x-devonthink-item://1EA9311E-0B9E-49F7-8D6E-4C4187A838C4?page=10) -- [Answer](x-devonthink-item://B1CB2E8F-5D04-49EE-8274-043871389D28?page=5)
## neurogenic shock
- [ ] 19Q: [Neck injury](x-devonthink-item://D4C19F6F-0718-4AD7-BDC4-34B460451B98?page=1) -- [Answer](x-devonthink-item://736EC9CD-AC9C-4588-BA1E-F4AD190CBA47?page=10)
- [ ] 20Q: [Hypotensive Trauma Patient](x-devonthink-item://73409C77-B2FA-4E0A-AEB3-5EB284457F0C?page=50) -- [Answer](x-devonthink-item://5A848952-80E3-4184-B553-368412A69917?page=33) -- [prop](x-devonthink-item://2A1F4A99-92AE-4C8E-B325-AE448BD46AC6?page=11)
## penetrating neck injury questions
- [ ] 21Q: [Penetrating neck injury](x-devonthink-item://8AAAF35C-CCF4-4157-9551-5B05727AA0CD?page=9) -- [Answer](x-devonthink-item://FDFBA3A1-6207-4204-AB6D-7483D80C5B5C?page=9)
- [x] DUPLICATE Q: [Neck Injury](x-devonthink-item://8AAAF35C-CCF4-4157-9551-5B05727AA0CD?page=9) -- [Answer](x-devonthink-item://FDFBA3A1-6207-4204-AB6D-7483D80C5B5C?page=9)
- [x] 22Q: [Penetrating Neck Injury](x-devonthink-item://C88FD92C-E0CB-48A1-8D73-F20489FA4E6C?page=2) -- [Answer](x-devonthink-item://98D17FA0-225B-4E94-B21C-4E36D5C76A7C?page=25) -- [prop](x-devonthink-item://093F49C6-2E32-460E-9C00-3E9F15CD417E?page=11)
- [ ] 23Q: [Penetrating Neck Injury](x-devonthink-item://73409C77-B2FA-4E0A-AEB3-5EB284457F0C?page=17) -- [Answer](x-devonthink-item://5A848952-80E3-4184-B553-368412A69917?page=11) -- [prop](x-devonthink-item://2A1F4A99-92AE-4C8E-B325-AE448BD46AC6?page=5)
## ppe
- [ ] 24Q: [MERS](x-devonthink-item://1A2C485F-D4AD-4821-AFF2-452BA753717F?page=12) -- [Answer](x-devonthink-item://FD716379-1A77-4B5B-B257-1154995ECA6E?page=6)
## spinal cord injury
- [x] DUPLICATE Q: [Neck Injury](x-devonthink-item://8AAAF35C-CCF4-4157-9551-5B05727AA0CD?page=9) -- [Answer](x-devonthink-item://FDFBA3A1-6207-4204-AB6D-7483D80C5B5C?page=9)
## spinal injury
- [ ] 25Q: [Paralysis after Rugby Injury](x-devonthink-item://CDB16617-3785-40E5-B8BE-5668D2D7A3E7?page=4) -- [Answer](x-devonthink-item://A6CA01E8-9551-45E7-8617-441BE3DBB5D7?page=3)
## spinal shock
- [x] DUPLICATE Q: [Neck injury](x-devonthink-item://D4C19F6F-0718-4AD7-BDC4-34B460451B98?page=1) -- [Answer](x-devonthink-item://736EC9CD-AC9C-4588-BA1E-F4AD190CBA47?page=10)
## trauma
- [ ] 26Q: [Traumatic arrest](x-devonthink-item://1A14F7A1-E434-47A6-BC68-AF2DD1A7C090?page=16) -- [Answer](x-devonthink-item://736EC9CD-AC9C-4588-BA1E-F4AD190CBA47?page=38)
- [ ] 27Q: [Open ankle fracture](x-devonthink-item://09493372-578D-4C97-972A-EEC617B38B53?page=8) -- [Answer](x-devonthink-item://A0D348CE-FCD4-4ECD-BE21-6CA73F6DE8CD?page=4)
- [x] 28Q: [Motorbike accident](x-devonthink-item://1A2C485F-D4AD-4821-AFF2-452BA753717F?page=46) -- [Answer](x-devonthink-item://FD716379-1A77-4B5B-B257-1154995ECA6E?page=30) -- [prop](x-devonthink-item://1A2C485F-D4AD-4821-AFF2-452BA753717F?page=65)
- [ ] 29Q: [Motorcycle Vs Kangaroo](x-devonthink-item://73409C77-B2FA-4E0A-AEB3-5EB284457F0C?page=36) -- [Answer](x-devonthink-item://5A848952-80E3-4184-B553-368412A69917?page=25)
## vasopressors
- [ ] 30Q: [Calf pain](x-devonthink-item://4134DDB3-6E12-474A-9F6F-64135C0C6048?page=27) -- [Answer](x-devonthink-item://AC92B5F1-8EE6-461A-B03E-F70AE7DC1275?page=27)
- [ ] 31Q: [Unwell with UTI](x-devonthink-item://6092BF31-E542-4019-8E17-0C628DD3B0F1?page=15) -- [Answer](x-devonthink-item://E15CEB64-C6A5-4A7D-84B4-E7D1DC667B0E?page=10)
# OSCE
- [RMH 2023.2 station 6](x-devonthink-item://6DB0381A-FFB9-43F8-8AA9-37B99D1E5905)