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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. ????????? Cervical spine injuries occur frequently after major trauma ?????????. SAFE AND PROMPT CERVICAL SPINE CLEARANCE. Sequelae of not clearing cervical spine safely and promptly is enormous.

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THE CERVICAL SPINE IN THE OBTUNDED PATIENT Lisa Harkness- Adult NP Trauma

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  1. THE CERVICAL SPINE IN THE OBTUNDED PATIENT Lisa Harkness- Adult NP Trauma

  2. HOW TO CLEAR • ????????? • Cervical spine injuries occur frequently after major trauma • ?????????

  3. SAFE AND PROMPT CERVICAL SPINECLEARANCE • Sequelae of not clearing cervical spine safely and promptly is enormous

  4. 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......

  5. SPINE BOARDS ? • Good for pre hospital transport only –complications

  6. SAFE AND PROMPT CERVICAL SPINE CLEARANCE • Improperly clearing and missing injuries..... • Potentially devastating

  7. HOW ? • CLINICAL CLEARANCE OR IMAGING • IMAGING – What /When ? • Plain x-rays • CT scans • MR • Flex Ex

  8. HOW? • CLINICAL CLEARANCE ALONE ?

  9. HOW? • CLINICAL CLEARANCE ALONE ?

  10. IMAGING • Who needs imaging • When do we do Xrays vs CT vs MR • How significant is a ligamentous injury

  11. 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

  12. 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

  13. 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.

  14. IMAGING -XRAYS • XRAYS – provide no additional info and miss injuries compared to CT

  15. IMAGING – FLEX-EX • RECENT STUDIES? • No class 1 or 2 evidence • Anecdotal reports only • Majority – no additional info over CT

  16. IMAGING – FLEX -EX • Flex –ex -no additional information over CT

  17. IMAGING -CT • CT cross sectional images • Sensitive for finding fractures – 98 % • CT Cspine radiation? 1 : 10000  Cancer

  18. 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?

  19. 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%

  20. 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

  21. 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!

  22. 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

  23. 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

  24. 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

  25. 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

  26. CONCLUSIONS • Flex-Ex – no additional info over CT/case reports only • Abnormal CT – consult • Neuro findings – consult • N CT and N MR - cleared

  27. 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

  28. LHSC TRAUMA NEGATIVE CT does NOT equal cleared at LHSC at present

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