Emergency Department Management
Emergency Department Management
When a patient with a potential cervical spine injury arrives in the ED, every effort should be made to protect the cervical spine until it is assessed. Sedation may be required in the combative patient. Patients should be removed from backboards as soon as the clinician determines that the spine is stable. If removed from the board, the patient should be instructed to remain supine. Cervical collars should also be removed as soon as the clinician determines that no serious cervical injury exists.
Spine boards were developed as a means of extricating patients from a motor vehicle while maintaining spine precautions; they were not intended as an immobilization device.10 Leaving the patient on the board is not necessary for immobilization. Patients who arrive in the ED on a spine board should be evaluated immediately. If continued spinal immobilization is needed, the patient should be log rolled off the board and placed on a firm mattress. This transfer may be briefly delayed for initial stabilization and radiographs, but leaving the patient on the board for convenience is inappropriate.11 Unfortunately, presently there is no non-radiographic method for determining the presence or absence of potentially unstable thoracolumbar fractures and some experts believe that the spine board is helpful in protecting this portion of the spine. Local practice varies with regards to whether the patient needs to remain on the spine board until their entire spine has been clinically or radiographically cleared. There is no published consensus on this matter.
Unwarranted spinal immobilization can expose patients to the risks of iatrogenic pain,12,13 increased intracranial pressure,14,15 skin ulceration,16-18 aspiration19,20 and ventilatory compromise,19,21 as well as longer hospital stays and increased costs. The potential risks of aspiration and ventilatory compromise are of concern because death from asphyxiation is one of the major causes of preventable death in trauma patients.22
Allowing patients to remain on the backboard for prolonged periods of time adds to patient discomfort and can increase the risk of pressure ulcers, especially in patients with spinal cord injury.24 If the patient needs to remain on the spine board past initial radiographs, pad the bony prominences. This significantly increases patient comfort and decreases the likelihood that the patient will move around on the board to achieve comfort.25 It may be difficult for the patient to differentiate pain due to an injury from pain iatrogenically created by prolonged length of time on the board.24
There is still some controversy regarding helmet and shoulder pad removal once the patient has arrived in the ED. It is possible to obtain initial cervical spine radiographs with the protective gear in place, but adequate films and visualization can be difficult in this setting. Football helmets and shoulder pads impair visualization of the 1st, 2nd, 3rd, and 6th cervical vertebrae.39 If accurate visualization and interpretation of radiographs is not possible without removal of protective gear, remove the gear with extreme caution. Gather and coordinate as many people as necessary to provide proper immobilization during the removal process. An athletic trainer or team physician can provide valuable assistance in this process.26
Airway Management Considerations
Direct laryngoscopy and orotracheal intubation with manual in-line stabilization has become the standard of care for airway management in the trauma patient. It is the simplest and most effective means for obtaining an airway in most trauma patients.27
Spinal immobilization can complicate the ability to secure an airway. Credible case reports of neurologic deterioration as a result of direct laryngoscopy and orotracheal intubation with manual in-line stabilization are rare.28,29
The currently available body of literature suggests that direct laryngoscopy and orotracheal intubation are not likely to cause clinically significant cervical spine movement. Manual in-line stabilization does not limit the movement that does occur and may actually increase subluxation at unstable segments.27-38Additionally, in-line stabilization may worsen the laryngoscopic view, which can lead to failed intubation with associated hypoxia and secondary neurologic injury.31,40-44 Manoach and Paladino published an excellent review of this literature in 2007 and noted that the reported data on direct laryngoscopy and orotracheal intubation with manual in-line stabilization in injured people consisted of only 9 case series: 5 of the studies were adequately described and reported 120 patients with unstable injuries and salvageable cord function who underwent direct laryngoscopic orotracheal intubation with no associated intubation related complications.27 Despite the evidence, physicians are understandably hesitant to forgo manual in-line stabilization during even a difficult intubation as the potential for exacerbating an injury exists. Physicians should focus on minimizing cervical movement while securing definitive airway access as quickly as possible.
Direct laryngoscopy and orotracheal intubation will be successful in most cases of airway management in the patient with a potential cervical spine injury. However, when difficult airways are encountered and intubation fails, alternative approaches must be available. Nasotracheal intubation is less successful than orotracheal intubation and requires a spontaneously breathing patient. It is contraindicated when there is suspicion of craniofacial injuries.45 Cricothyrotomy is the ultimate procedure for a failed airway. Equipment for this procedure must be readily available anytime an intubation is attempted.
An accurate history is particularly important in the evaluation of patients with blunt cervical trauma, as it is an important factor in deciding who needs cervical spine imaging.46
If the injury is the result of a motor vehicle collision, it is important to determine where the patient was seated, if restraints were used, if airbags deployed, where the vehicle was hit, and if the patient was ejected from the vehicle. This information may help determine the severity of the mechanisms of injury. Note the use of any intoxicants by the patient, since an intoxicated patient may have an unreliable physical examination. It is often reported that the patient was or was not ambulatory at the scene. This fact is of limited importance within the setting of potential cervical spine injury, as patients with cervical spine fractures may be ambulatory, especially if their judgment of pain perception is impaired by alcohol. Despite being clinically intuitive, evidence of this phenomenon in large prospective trials demonstrating the effect of alcohol intoxication and missed diagnosis of cervical spine fractures is lacking.47 If the mechanism of injury was from a fall, determine from what height the patient fell and if any events preceded the fall, such as syncope or seizure. Question the patient about the presence of pain. In addition, elicit associated signs and symptoms such as loss of consciousness or related medical complaints. Presence of weakness or paresthesias is of particular importance.
Talk to the patient immediately and ask their name, what happened, and where they are hurting. This simple assessment provides information about the airway, the patient's mental status, and the patient's ability to ventilate. Ask if they have weakness or numbness anywhere and have them move all 4 extremities. Inspect and palpate the entire neck and back for any obvious injury, taking care to maintain spinal precautions. Open the collar to examine the neck for crepitus, hematoma, or laceration. Any of these have the potential to compromise the airway and can easily hide under a cervical collar. Note whether the patient has focal vertebral tenderness or paraspinal muscle tenderness. However, the presence of only paraspinal muscle tenderness does not exclude vertebral injury. Posterior midline tenderness had only an 86% sensitivity for clinically important cervical spine injury in the study that framed the basis of the Canadian cervical spine rule.46 This is in contrast to the NEXUS data. When a fracture is in a superficial position, there is focal tenderness on palpation. Palpation at a distance from the fracture may not cause tenderness. Additionally, tenderness may not be elicited if the fracture is in an area with there is greater muscle development. Direct palpation of a vertebral body is not possible. This may explain why palpation in the posterior midline, which may be at a considerable distance from a vertebral fracture, may fail to elicit focal tenderness in an occasional patient.48
The neurological examination of a patient with any spine injury is key and should be performed as soon as possible. Serial examinations should be performed when indicated to assess the possibility of evolving spinal cord injury. Simple observation of the patient may provide important clues. Asymmetric movement or absence of movement of extremities, abdominal breathing, priapism, and involuntary loss of bladder or bowel contents may be noted.
The patient's motor function should be examined. The minimal motor function, whether it be full motor strength in all extremities or completely flaccid, should be determined. Even the slightest movement in a finger or toe is meaningful with regards to preserved spinal function.
For the sensory examination, a dermatomal map can be used to aid in identifying the area of deficit. This should initially be done with light touch, moving from an area of diminished sensation to an area of sensation as patients are more sensitive to the appearance of sensation than to its disappearance.49 Appreciation of pinprick sensation should be assessed as well. Light touch affects the posterior column while pinprick affects the anterior column. In anterior cord syndrome, light touch appreciation is present despite serious cord damage. Areas of preserved sensation within an affected dermatome or below the level of apparent total dysfunction, even in patients with complete paralysis, indicate that the patient has a very good chance of functional motor recovery.49 Repeat sensory examinations are important since progression of deficit occurs in a cephalad direction. Impending respiratory failure should be expected.
The presence or absence of reflexes and rectal tone should be noted. Spontaneous respirations with elevation and separation of the costal margins on inspiration indicate normal thoracic innervation.50 An unconscious or intoxicated patient may be difficult to evaluate neurologically. Observation for spontaneous movement of the extremities or response to noxious stimuli is often the only initial option.
Cervical spine injuries are associated with other injuries, including maxillofacial injury, head injury, abdominal injury, and other vertebral injuries.51-54 Therefore, a careful secondary survey is needed after initial stabilization is complete.
Lisa Freeman Grossheim; Kevin Polglaze; Rory Smith
April 2, 2009