the cervical spine in the obtunded patient lisa harkness- adult np trauma

THE CERVICAL SPINE IN THE OBTUNDED PATIENT

Lisa Harkness- Adult NP Trauma

HOW TO CLEAR

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• Cervical spine injuries occur frequently after major trauma

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SAFE AND PROMPT CERVICAL SPINECLEARANCE

• Sequelae of not clearing cervical spine safely and promptly is enormous

SAFE AND PROMPT CERVICAL SPINE CLEARANCE

• Delay in clearing leads to increase in mortality and morbidity

• Frequently see increase in Pneumonias,UTIs, DVTs, PEs, Delirium, Skin Breakdown......

SPINE BOARDS ?

• Good for pre hospital transport only –complications

SAFE AND PROMPT CERVICAL SPINE CLEARANCE

• Improperly clearing and missing injuries.....• Potentially devastating

HOW ?

• CLINICAL CLEARANCE OR IMAGING

• IMAGING – What /When ?• Plain x-rays• CT scans• MR• Flex Ex

HOW?

• CLINICAL CLEARANCE ALONE ?

HOW?

• CLINICAL CLEARANCE ALONE ?

IMAGING

• Who needs imaging

• When do we do Xrays vs CT vs MR

• How significant is a ligamentous injury

IMAGING -XRAYS

• Giffen et al 1199 blunt trauma pts with neck pain, altered mental status or neuro deficit

• Pts had both CT and plain films• Injury found on 75 pts with Xray• Ct found injury on 116 pts with CT• Xray missed injuries• CT no missed injuries

IMAGING - XRAYS

• Diaz et al prospective study with 1066 pts distracting or altered mental status

• All pts had 5 views x-ray and CT• Xray – missed 90 of 172 stable injuries and 5

of 29 unstable injuries• CT – missed 3 of 172 stable injuries , no

unstable injuries missed

IMAGING - XRAYS

• Brohi et al – similar findings• 437 comatose blunt trauma pts – Xray missed 14 of

31 injuries – CT no misses

• Mathan et al – similar 667 pts

• Holmes – meta analysis – Xrays to CT• Concluded Xray 52% sensitivity compared to CT

98% sensitivity.

IMAGING -XRAYS

• XRAYS – provide no additional info and miss injuries compared to CT

IMAGING – FLEX-EX

• RECENT STUDIES?

• No class 1 or 2 evidence• Anecdotal reports only• Majority – no additional info over CT

IMAGING – FLEX -EX

• Flex –ex -no additional information over CT

IMAGING -CT

• CT cross sectional images • Sensitive for finding fractures – 98 %• CT Cspine radiation? 1 : 10000 Cancer

IMAGING – Pt with Negative CT

• What do we do now? N CT

• Clear pt and remove collar?• Leave in collar until pt wakes up?• Do MR and hope it gives us more info and

have fun while in MR for 3 hours?

CONCERNS?

• What are we really worried about• CT Negative NO FRACTURES• What about ligamentous injuries• Incidence of ligamentous injuries in setting of

negative CT is VERY LOW 5%• Incidence of a clinically significant injury

UNKNOWN but VERY LOW 1%

IMAGING-MR

• MR – Road trip from h...!

• Never a quick easy trip to MR• Time of MR – best images for soft tissue injury reported to be at 24 – 72 hour post injury

IMAGING-MR

• MR more sensitive than CT for soft tissue injury

• MR less sensitive than CT for fractures• One study MR missed 45% fractures when

used alone to clear obtunded pt• N CT AND N MR CLEARED!

IMAGING – N CT and MR

• Coharta et al -51 obtunded pts , 46 N CT, MR positive 10 of 46 – unclear on clinically significance of injuries found

• Sarani et al – 46 obtunded pts with CT N, MR positive with 5 – no surgeries required, all tx in collar for 6 weeks

IMAGING – N CT and MR

• Hogan et al – 366 obtunded pts with N CT,MR 97% N, 2% cord contusion, 1%ligamentous injury

• Cono et al- 115 obtunded pts with N CT, MR found 6 non significant injuries

MR CONCLUSIONS ?

• Are we able to make any conclusion re N CT and need for MR?

• EAST Guidelines - unable to make definitive recommendation re need or not for MR after N CT

• EAST - up to individual organizations

CONCLUSIONS

• Spine clearance needs to be prompt but safe• Cervical collar – remove ASAP• Spine boards – remove ASAP• CT – yes• Plain Xrays – provide no additional info and

miss injuries

CONCLUSIONS

• Flex-Ex – no additional info over CT/case reports only

• Abnormal CT – consult• Neuro findings – consult• N CT and N MR - cleared

CONCLUSIONS• Did we need to MR with N CT – does it provide any

additional info / is it safer?

• For Now – Safer –no missed injuries

• LHSC N CT N MR Cleared

• More Research Needed

LHSC TRAUMA

NEGATIVE CT does NOT equal cleared at LHSC at present