A Bathroom Fall, Then No Movement Below - Rheumatology clinical simulation case. A 68-year-old woman with long-standing erosive seropositive rheumatoid...
A 68-year-old woman with long-standing erosive seropositive rheumatoid arthritis on chronic low-dose prednisone and methotrexate trips on a wet bathroom floor at home. She cannot move her arms or legs on arrival and reports new inability to feel her fingertips, no urination since the fall, and a sensation of electric shocks running down her neck when she tries to lift her head. Erosive RA for 22 years; chronic prednisone 5 mg daily, methotrexate 15 mg weekly, folic acid supplementation. Prior cervical spine radiographs two years ago showed atlantoaxial subluxation of 6 mm. Lives alone; neighbor heard the fall and called EMS.
Acute Resuscitation Milestones & Priorities
Clinical phases and key interventions encountered in this emergency module:
Initial Resuscitation Bay Triage & Spinal Immobilization
Postoperative Neurocritical Care & Rehabilitation Disposition
High-Yield Clinical Pearls
Long-standing erosive RA predisposes to atlantoaxial subluxation; a low-energy fall can produce high cervical cord injury in these patients.
Manual in-line cervical stabilization must be maintained during every transfer; never remove the collar or allow active neck movement until imaging excludes ligamentous and bony injury.
Definitive imaging of suspected atlantoaxial injury begins with thin-slice CT of C1-C2; MRI confirms cord compression and guides surgical urgency.
Awake fiberoptic intubation is the airway of choice in unstable high cervical injuries to avoid cord compression during laryngoscopy.
Postoperative MAP augmentation to 85-90 mmHg for 48-72 hours supports spinal cord perfusion and improves neurologic recovery.
Routine high-dose methylprednisolone is no longer recommended in acute spinal cord injury due to lack of motor benefit and increased complications.
Test Your Clinical Reasoning in Real Time
Step into the active clinician role for this case. Order diagnostic tests, analyze live laboratory panels, and navigate branching clinical decisions with real-time feedback.