A 28-year-old male has been involved in a high-speed motor vehicle crash 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) Outline your approach to clearing the cervical spine in this man. Justify your answer.
b) List the potential problems associated with the inability to clear the cervical spine at an early stage.
- The patient is sedated and so the cervical spine cannot be cleared clinically so will keep collar in place. Also check correct size and fitting.
- Radiological clearance
- Plain C-spine films are no longer suggested as routine part of trauma series but fractures on CXR and pelvic XR associated with increased risk of C-spine injury
- High resolution 64 slice helical CT of the entire cervical spine and T1 with sagittal and coronal reconstructions
- Review with radiologist
- 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.
If no bony injury but need to exclude ligamentous injury, perform MRI.
There is no 100% accurate method to exclude C-spine injury and management is a balance of risk-benefit for that individual. In some cases clearing the C-spine early may not be possible and leaving the collar in situ is a balance between management of potentially “unstable” C-spine and the risk of complications from the collar.
- 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
This question closely resembles Question 4 from the second paper of 2011.