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<< Acute Spinal Injuries: Assessment and Management
Risk Management
1. Failure to prioritize the ABCs over potential ASCIs.
2. Failure to consider a spine fracture.
4. Failure to expedite the removal of immobilization devices, when possible.
5. Using clinical judgment rather than a clinical decision rule to rule out cervical spine injury.
7. Failure to appreciate that the elderly are at high risk for spine fractures.
8. Failure to visualize the entire cervical spine on the x-ray study.
9. Failure to appreciate that a normal x-ray or MDCT does not rule out ligamentous injuries or SCIWORA.
10. Failure to appreciate that administering a high dose of MPSS poses risks.
a. Respiratory compromise or hypoperfusion will cause death quickly.
b. If there is a tenuous airway, use in-line cervical immobilization and definitively secure it.
2. Failure to consider a spine fracture.
a. If a patient is obtunded or altered, assume that there is a fracture until proven otherwise.
b. Do not attribute the back pain to a more benign cause in the setting of a high-energy blunt trauma.
c. Until proven otherwise, assume the worst. Think “spine fracture” or “ASCI” until proven otherwise.
3. Attributing the lack of movement over a joint to pain from a fracture.b. Do not attribute the back pain to a more benign cause in the setting of a high-energy blunt trauma.
c. Until proven otherwise, assume the worst. Think “spine fracture” or “ASCI” until proven otherwise.
a. As in Pitfall #2, assume the worst.
4. Failure to expedite the removal of immobilization devices, when possible.
a. Immobilization poses its own hazards
(see Table 1).
b. Pressure sores develop within hours in patients placed on backboards.
c. Expedite surgical fixation if there are unstable fractures.
(see Table 1).
b. Pressure sores develop within hours in patients placed on backboards.
c. Expedite surgical fixation if there are unstable fractures.
5. Using clinical judgment rather than a clinical decision rule to rule out cervical spine injury.
a. Clinical judgment is not sufficient anymore.
b. Use the prospectively validated NLC or CCR to clear patients.
c. If there is any question, get the study.
6. Failure to understand the limitations of a clinical decision rule.b. Use the prospectively validated NLC or CCR to clear patients.
c. If there is any question, get the study.
a. The reliability of the NLC has not been validated in young children.
b. It should be used with a great deal of caution, if at all, in this patient population.
b. It should be used with a great deal of caution, if at all, in this patient population.
7. Failure to appreciate that the elderly are at high risk for spine fractures.
a. Elderly people, especially elderly females with osteoporosis, are at high risk for spine fractures and ASCIs.
b. Seemingly minimal trauma can cause fractures in this patient population.
b. Seemingly minimal trauma can cause fractures in this patient population.
8. Failure to visualize the entire cervical spine on the x-ray study.
a. The entire cervical spine should be seen on plain films.
b. If they are inadequate, get a multidetector computed tomography scan (MDCT).
b. If they are inadequate, get a multidetector computed tomography scan (MDCT).
9. Failure to appreciate that a normal x-ray or MDCT does not rule out ligamentous injuries or SCIWORA.
a. Although rare, these injuries do occur.
b. In the setting of normal x-rays or MDCT where the patient complains of persistent pain or neurologic symptoms, consider further studies.
c. An MRI or continued cervical spine immobilization with delayed FE films is recommended in patients with persistent pain and a negative MDCT.
b. In the setting of normal x-rays or MDCT where the patient complains of persistent pain or neurologic symptoms, consider further studies.
c. An MRI or continued cervical spine immobilization with delayed FE films is recommended in patients with persistent pain and a negative MDCT.
10. Failure to appreciate that administering a high dose of MPSS poses risks.
a. Severe pneumonia is more likely in these patients.
b. The NASCIS studies also showed a trend towards severe sepsis.
b. The NASCIS studies also showed a trend towards severe sepsis.
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