24. Clearing the cervical spine in the unconscious polytrauma victim

Question 1

A 24-year-old man was admitted to the accident and emergency
department having been found at the side of the road. He is
haemodynamically stable and appears to have sustained only facial and
head injuries following a primary survey. His GCS is 3/15 and so you
decide to intubate him.

Would you take any special precautions?

Answer 1

ATLS protocol dictates airway management with cervical spine control.

This is an emergency anaesthetic in a trauma victim.

Assume a full stomach so RSI is indicated.

Assume a fractured C-spine until this is proven otherwise.

Difficult airway suspected in facial trauma and so equipment
and expertise should be immediately available to deal with this.

Question 2

What would you do to protect his neck?

Answer 2

Following ATLS guidelines, he should be fully immobilised with:

Spinal board.

Appropriate hard collar.

Head blocks or sandbags either side of his head.

Tape across his chin and forehead.

For intubation:

Remove the tape, blocks and collar.

Manual in-line immobilisation is maintained by a dedicated person who
ensures that the head and neck remain neutral, whilst allowing access to
the face and neck.

Once the airway is secured, the cervical spine must be fully immobilised
again.

Question 3

What imaging is required in this patient?

Answer 3

Trauma series’ films of lateral C-spine, CXR and AP pelvis.

CT head as he has an altered conscious level.

The UK Intensive Care Society advocates CT scanning of the cervical spine
for any patient who is unconscious and having a CT scan of the head.

When time permits, an AP of the C-spine and an open mouth view of the
odontoid peg are required. An adequate film must be ensured, and this
should show down to the C7/T1 junction.

Further C-spine views such as a swimmer’s view may sometimes be required.

Question 4

Let’s say the patient needs to be ventilated on the ITU for several days
owing to his head injury. What are the problems with leaving him fully
immobilised?

Answer 4

Pressure sores are common after the prolonged use of hard collars,
particularly after 48–72 hours.
These can complicate spinal surgery as well as becoming a source for sepsis
and may even require skin grafting.

Hard collars have been demonstrated to raise ICP, which will obviously
disadvantage the significant group of patients who have a co-existing head
injury

Airway problems are more common.

Insertion of neck lines is more problematic.

Physiotherapy is more difficult.

Thromboembolic disease is more common.

In patients who are nursed supine and immobilised, there are higher rates
of enteral feeding failure associated with gastric stasis, aspiration and
higher rates of pneumonia.

Increased risk of bacteraemia and sepsis due to impaired basic hygiene (care
of central venous catheters, oral care) and the need for at least four staff to
log roll (cross-contamination).

Question 5

Would you leave the full immobilisation in place then or remove it?

Answer 5

ATLS guidelines traditionally require:
Normal plain X-rays

Normal skeletal and neurological examination

Carried out in a sober, conscious patient with no distracting injuries.

Obviously, this is not possible in a sedated patient.

One has to weigh the risks of an undiagnosed unstable ligamentous injury
or a missed unstable fracture against the risks of prolonged immobilisation.

Question 6

What would you do then? Do you know of any guidelines in this area?

Answer 6

Those who will not be clinically assessable inside 48–72 hours.

Typically have severe head injuries, multiple injuries or organ failures.

Prolonged immobilization places the patient at risk and 90%–95% of these
will not have a cervical spine injury.

These patients should have their necks cleared using combinations of plain
films and CT scanning.
Greater than 99.5% of cervical spine injuries would then be detected after expert interpretation.

Question 7

Cervical spine injury

Answer 7

There are approximately 1000 cases of cervical spine injury in the UK each year.

These injuries complicate 2%–5% of all blunt polytrauma cases.

The presence of a severe head injury increases the relative risk of a
C-spine injury by up to 8.5 times.

A missed or delayed diagnosis of cervical spine injury may increase the
rate of severe neurological injury by up to 10%.

Ligamentous injuries can occur in those whose bony cervical vertebrae
are not fractured, but excess movement could potentially allow for
damage to the cervical cord.

A review of various studies and surveys tried to quantify the risks of
isolated ligamentous injury and found this risk to be consistently
under 1%, typically 0.1%–0.7%.