Question 4

Created on Sat, 05/16/2015 - 04:14
Last updated on Thu, 09/24/2015 - 00:22
Pass rate: 33%
Highest mark: 7.0

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An 18-year-old male has been involved in a high-speed motor vehicle accident and admitted to your hospital. His initial GCS at the scene was 5 (E2, V2, M1). He has been intubated and has a hard collar in place.

a) What is your approach to the management of the hard collar and justify your practice? 


b) List the potential problems associated with inability to clear the cervical spine at an early stage? 

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College Answer

a)

The patient is sedated and so the spine cannot be cleared clinically so will keep collar in place. Also check correct size and fitting. Firstly clear radiologically – review all images and obtain formal radiologist reports. Trauma series (typically only CXR and pelvic XR as C-spine films are low yield and no longer suggested as a routine) looking for obvious vertebral fractures +/- dislocations as patients with a fracture on CXR or PXR have higher risk of C-spine fracture.

High resolution 64 slice helical CT of the entire cervical spine and T1 with sagittal and coronal

reconstructions - With technically adequate studies and experienced interpretation, the combination of multi-slice helical CT with reconstruction CT scanning provides a false negative rate of < 0.1%

Clear radiologically and if low risk for ligamentous injury and patient unlikely to be extubated in 24-48 hr, remove collar.

Or: If no bony injury but need to exclude ligamentous injury, perform MRI.

Or: If bony injury present assessment for instability and surgery and immobilization as indicated in discussion with spinal surgeons.

b)

  • Prolonged immobilization is associated with significant morbidity
  • Decubitus ulceration (especially related to cervical collar)
  • Increased need for sedation
  • Delayed weaning from respiratory support
  • Delays in percutaneous tracheostomy
  • Central venous access difficulties
  • Enteral feeding intolerance due to supine positioning
  • Pulmonary aspiration due to supine positioning
  • DVT due to prolongation of immobility
  • Increased risk of cross-infection due to extra staff / equipment involved in position changes
 

Discussion

The college answer is written strangely. I have written my own answer... It may not be any better. It answers the question "how do you clear the C-spine of an non-communicative patient"

  • Maintain spinal precautions and keep collar on, ensuring it is properly fitted.
  • Seek to clear the C-spine within 72 hours
  • Perform helical CT of C-spine with multiplanar reconstructions
  • Solicit an expert radiologist report on the helical CT
  • If radiologically there is bony injury, the collar stays on and a neurosurgical referral is made
  • If radiologically there is no bony injury but suspicion of ligamentous injury is raised by abnormal CT findings,
    • An MRI of the C-spine is performed
    • An expert radiologist opinion is sought regarding the possibility of ligamentous injury
      • If the MRI confirms ligamentous injury, the collar stays on and a neurosurgical referral is made
      • Otherwise, the MRI clears the C-spine and the collar may be removed
  • If radiologically there is no bony injuries nor suspicion of ligamentous injury,
    • And extubation is not planned in the next 48 hours,
      • Then the collar may be removed.
    • If extubation is planned in the next 48 hours,
      • Consider leaving collar in situ and clearing the C-spine clinically once the patient is alert and cooperative, provided there are no distracting injuries.

The best resource I have found as a complete C-spine clearance protocol was the 2006 publication from the Alfred in Melbourne.  Why was it the best?  Well. Firstly, it's on the health.gov.au website, so its local policy. Secondly, its based on international published data, and is well-referenced.  Lastly, the college answer for question 4(b) was cut and pasted verbatim from the Alfred protocol, page 5.

As for problems with being in a hard collar, here is a list of problems from  a 2004 review by Morris and McCoy (quoted in Oh's Manual).

Problems associated with prolonged C-spine immobilisation

  • Pressure areas under the collar
    • Source of sepsis
    • Need for skin grafts
    • Increased hospital stay
  • Increased intracranial pressure
  • Airway is made more difficult by in-line stabilisation
  • Central venous access is made more difficult (IJ is out of bounds)
  • Oral care is made more difficult, increasing the risk of VAP
  • Nutrition is affected:
    • Gastroparesis and ileus results from prolonged immobility
    • Aspiration risk is increased by supine position
  • Physiotherapy is delayed or impossible
  • A greater risk of DVT/PE results from prolonged immobility
  • A minimum of 4 nursing staff are required to turn the patient.

References

Brohi K, Healy M, Fotheringham T, Chan O, Aylwin C, Whitley S, Walsh M. Helical computed tomographic scanning for the evaluation of the cervical spine in the unconscious, intubated trauma patient. J Trauma. 2005 May;58(5):897-901.

Ackland, HM. The Alfred Spinal Clearance Management Protocol. 2006. The Alfred Hospital, Melbourne, Australia.

Chiu, William C. MD; Haan, James M. MD; Cushing, Brad M. MD; Kramer, Mary E. RN, and; Scalea, Thomas M. MD Ligamentous Injuries of the Cervical Spine in Unreliable Blunt Trauma Patients: Incidence, Evaluation, and Outcome Journal of Trauma-Injury Infection & Critical Care: March 2001 - Volume 50 - Issue 3 - pp 457-464

J L Harrison, BA (Hons)1 and  S J Ostlere, FRCP, FRCR2 Diagnosing purely ligamentous injuries of the cervical spine in the unconscious trauma patient British Journal of Radiology (2004) 77, 276-278