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C-spine Trauma: in a town with no CT

I worked for 4 years in a town with no CT (but plenty of beer) – and it is fair to say that the protocols for managing C-spine trauma were often makeshift.  Logistics rather than clinical acumen often determined who got a CT rather than ‘just’ clinical exam and a set of plain films.  But…. why should my patient get less than gold-standard care – just because of geography?   I realize this is a bit idealistic, but when it comes to life-long disability – do we really want to take that risk?

Now in recent months there has been a lot of posting and banter about C-spine trauma on the popular medical blogs / podcasts.  So I thought I would trawl through the literature and come up with a pragmatic protocol for those of us who work in CT-isolation, or where it is not available 24/7.  Amusingly here is a hot debate about whether you need to MRI patients with pain and a normal CT – Yep, true!  We are not even close to that debate in regional Australia!

The logistics of distance mean that I break (‘scuse the pun) C-spine trauma into 3 main groups:

  1. The minor trauma – these are the patients whom you can clear with clinical history, exam and NO imaging is required.
  2. The fuzzy middle group: they cannot be cleared on clinical grounds for whatever reason, or they have failed the clinical clearance. Yet, they remain asymptomatic, have no high risk features –  your “gestalt” is that they are probably OK.
  3. The major trauma: these patients are high risk – based on the mechanism of injury, associated injuries or the presence of neurology suggestive of a cord injury

I will try and explain how I think each of these should be managed based on my reading of the recent evidence, the reality of rural practice and a measure of common-sense.  If you want to get some great background and refresher in anatomy I have a few suggestions for your valuable time:

OK, without further waffling – lets analyse these 3 groups and try to cook up a rough protocol for each.
In some ways this should be the easiest group – but is also the one that causes the most frequent consternation!
Clearing a C-spine is one of those moments in medicine when you just have to trust your call. This is especially true in the bush – if you decide not to clear them – you are probably committing them to a long transfer strapped to a spinal board: uncomfortable and expensive!
So how do you clear a C-spine clinically? Here is how I do it – I use MDCalc’s Canadian C-spine tool – but be warned – you have to use it properly. These rules are derived and validated by following the protocol to the letter – if you do not follow the protocol as described you cannot achieve the same sensitivity. The Canadian C-spine seems to be better than the NEXUS rule (NEJM, 2003) – but you must have an alert, sober, orientated and cooperative patient – so a lot of our customers are self-excluded! Scot Weingart describes an interesting combination of the 2 rules.
As the receiving doctor in a CT+ town – I really want to know that the patient has had a proper attempt at C-spine rule clearance – otherwise we are squandering valuable flight resources and irradiating unnecessarily.
This group includes the people whom you cannot clear clinically as they are too drunk, disorientated, in pain, etc to qualify for a clear Canadian C-spine rule PLUS those who have failed the rule – ie. they have tenderness, pain on rotation, are too old etc.
So according to the rules they get “imaging”.  Easy: off for a set of plain films, right?  well maybe not such a great idea.
A good number will have sub-adequate views, and then you need to ask – what is the sensitivity OR the negative predictive value of plain films for C-spine injuries…?  Well they are not so great – in fact the term ‘suck’ has been used to describe them!
This series from the Journ. Trauma 2009 showed a sensitivity of plain films c/w CT for serious injury of less than 50% – that is worse than a coin toss!
However, some protocols continue to advocate plain films as a ‘screen’ for fracture in the lower-risk groups.  I guess this means the patient who so nearly passed the clinical clearance test (eg. were just 65 years old only, had transient pain…) But it is a small group – so the role of plain films is vanishing rapidly.
So in summary – there are not many patients we can reliably clear with plain films if you follow the evidence and guidelines as written.
Therefore if you are in a CT-less town, and have one of these patients – you probably should transfer for a CT.  If you think they are low-end risk, and have a good set of films then it is a judgement call on your part.  Traditionally we have cleared patients on this basis – but is it still the standard of care?
This is really the easiest group to decide upon. Sure, the toughest to manage, but the easiest to make a call on C-spine imaging.
If you have a patient with a high-energy mechanism, bony tenderness, neurological signs or major injury (esp head) then you need not bother with plain films. These patients need transfer – not imaging. This is the scenario where you want to get them to a trauma centre ASAP – probably for more than their neck injury. Taking them through the Xray Dept, moving them 3 or 4 times – for a series of images will add little to your management! Assume they have an unstable injury and manage them appropriately. If you are wrong – great, if you are right – then you have done the right thing!
Finally a quick note on C-Spine collars
  • Rigid C-Spine collars are omnipresent in ED trauma patients, they are almost like religious artifacts – there is a lot of belief in their powers, but is there the evidence to back them up??
    • The Journ Emerg Med 2012 published an article by Holla which looked at healthy people and the effect of collars – basically they did not actually immobilize any more than the padded boards / straps and decreased mouth opening.
    • There is no hard evidence to say they actually decrease neurological injury / improve outcomes.
    • We all know they are a pain, ill-fitting and your worst enemy when trying to intubate!
    • So here is my take – immobilisation is good, collars are window dressing.  If you really want to keep the neck still – provide good analgesia and anti-emesis, supervise the patient closely (esp. if they are drunk, head-injured etc), they will need a nurse / doc by the bedside constantly to do this right!
    • If you use a collar  and it is causing problems: pressure, pain, airway obstruction or really making the patient hostile – then take it off and keep a close eye on them.  Prima non nocere.

Comments

  1. Great post Casey – real world medicine for the bush rather than ivory tower ‘scan everything’ tertiary hospital mentality

    One thing worried me though – you mention long transfers with patients strapped to a spinal board

    Do you still use these? The vac-mats seem much better for a long transfer…

    Still, that’s least of worries. Had a chap today with cauda equina (well I thought so) – history of metastatic carcinoma’

    So rang the spinal reg at local centre of excellence to discuss transfer, urgent MRI and options

    Got the ‘spinal Fellow’ on the line – was very rude “What does the MRI show”

    I dunno mate, I’m on Kangaroo Island…I want to transfer him to you to get an urgent MRI

    “I won’t see him until he’s had an MRI”

    Click and hung up on me.

    Cue 45 mins on the phone trying to find a harrassed ED reg or FACEM to explain that my patient was en route by RFDS and needed to go straight thro’ to MRI.

    You’d think for this neurosurgical emergency you’d get a bit of help…

    Thankfully trauma systems generally seem much better. Perhaps the topic of another discussion – how to improve trauma systems from a rural docs perspective and develop a transfer checklist?

  2. Casey Parker says:

    Hi Tim – yes we have the Vac mattress system – they are good, forgive the melodrama – still, not a lot of fun to go through for 24 hours I imagine!

    Yes, love the ivory tower approach to transfer!
    I had a Neurosurg Reg call and demand an explanation as to why the patient was not in his hospital stat. He only gave us 30 minutes to get the patient from Broome to Perth!
    I politely offered him an email with a Google map attached….

    I think I will write an open letter to Registrars everywhere – wan to be a co-author?
    Casey

  3. Kane Guthrie says:

    Hey Casey

    Great post and really please you mentioned about the C-spine collars aka the brain tourniquet, personally i feel they do more harm than good. Patients that have no neck pain after laying in one generally get neck pain – because there not designed for comfort.

    Agree complete with your approach take the collar off, give analgesia and monitor closely if they are becoming an issue.

    Kane

  4. last I looked NZ does not use vac mattresses. Probably found in some tertiary cupboard where the utility is not. Curious as the distance and time rural to tertiary (most often by road) can be long, and if you think rural Australia is cold on a winter night… plus “keep them warm” is lip service without

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