Cervical Spine Controversies · Soft Collar PROS •Simple •Easy to fit •More comfortable...
Transcript of Cervical Spine Controversies · Soft Collar PROS •Simple •Easy to fit •More comfortable...
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Cervical Spine Controversies
“Collars & Clinical Clearance”
Dr D Reed FACEM Director of Trauma Gosford Hospital June 2017
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Overview
• Cervical spine immobilisation
• How should we do it?
• Which collar should we use?
• Cervical spine clinical clearance
• How should we do it?
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Let’s consider a case…. and a few questions……
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I.M.I.S.T.
• I: 20 yr old male
• M: MVA driver rear ended at lights
• I: Sore neck & slightly sore chest and wrist
• S: HR 80 SBP 120 RR 20 GCS 15 SaO2 99% RA
• T: Immobilisation and collar and transfer
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What level of immobilisation?
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Which Collar Pre-Hospital?
VS VS
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Which Collar in ED?
VS VS
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Which Protocol to Clear?
VS
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So what is the evidence?
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What level of immobilisation?
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What level of immobilisation?
• There is little evidence to support routine use of full spinal immobilisation pre-hospital or in-hospital
• No randomised trials as per Cochrane Review below
• Both ATLS/EMST and APLS moving away from recommending full immobilisation
• Real world use seems to be largely restricted to inter-hospital transport of high risk patients
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ANZCOR 2016
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Which Collar?
VS VS
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Which Collar?
• There has been a lot of recent discussion in the trauma world about the lack of evidence for the use of stiff neck collars in the pre-hospital and ED settings
• Some groups have argued that collars should not be used in the pre-hospital setting for conscious patients while others have suggested the use of soft collars
• Evidence suggests that collars are not beneficial for patients with penetrating trauma
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Penetrating Neck Injury
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The British
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The Scandinavians
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The Americans
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ANZCOR 2016
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ANZCOR 2016
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Stiff neck
PROS
• Widely used
• Familiar
• Relatively simple
• No significant proven harm in blunt trauma if used properly
• No clear proven reason to change
CONS
• Uncomfortable
• Compliance issues
• Airway compromise
• Raised ICP
• Hyperextension
• Cadaver studies suggest may not stop movement
• Penetrating trauma harm
• No proven benefit
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Soft Collar
PROS
• Simple
• Easy to fit
• More comfortable
• Better tolerated
• Recent studies show no proven harm when compared to stiff neck collars
CONS
• Nil known
• Not proven to be better than stiff neck collars
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The Queenslanders
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The Queenslanders
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The Queenslanders
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Which Protocol to Clear?
VS
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Which Protocol?
• There are two good evidence based clinical decision rules for clinically clearing the c-spine without imaging: namely the NEXUS Criteria (NEXUS) and the Canadian C-spine Rules (CCR)
• There are pros and cons to both protocols and different organisations use different protocols or a combination of the two
• Overall prompt clinical clearance prevents potential harm from unnecessary immobilisation and radiation
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NEXUS Criteria
• 2001 NEJM - 34069 blunt trauma patients
• All ages and no specific exclusions
• Sensitivity 99.6% and specificity 12.9%
• Simple and emphasises clinical judgment
• Does specifically assess for drugs / alcohol /distracting injury
• Does not address low risk features on history
• Does not assess mechanism of injury
• Does not assess age
• Does not assess for pre-existing c-spine abnormality
• Does not assess neck movement
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Canadian C-Spine Rules
• 2001 JAMA - 8924 stable alert adults blunt trauma • 100% sensitivity and 42.5% specificity
• Excluded abnormal vitals (inc altered LOC) • Excluded pre-existing c-spine abnormality
• Identified age >65 & dangerous mechanism as high risk • Identified low risk features eg mobilise or delayed onset • Identified range of movement as important
• Did not use drugs/alcohol/distracting injury • Did not assess pain on movement
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Combined Protocol?
+
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What’s happening in NSW?
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ASNSW
>>
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Gosford & Wyong NSW 2015 “Clinically Clear or Comfort Collar”
Cannot clear >>>>>>
Clinically clear on arrival
(Combined Protocol)
>>>>>>
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St George NSW 2016 “Clinically Clear or Soft Collar Initially”
Cannot clear Within 1 hour >>>>>>
Clinically clear (Combined protocol) >>>>>>
# or neurology
>>>>>>>
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Any comments or questions before we look at that case again and get some of your opinions about what to do?
???????????
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So lets look at that case….
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I.M.I.S.T.
• I: 20 yr old male
• M: MVA driver rear ended at lights
• I: Sore neck & slightly sore chest and wrist
• S: HR 80 SBP 120 RR 20 GCS 15 SaO2 99% RA
• T: Collar and transfer
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Pre-hospital
• Which collar/immobilisation should be applied?
– Full spinal immobilisation?
– Stiff neck collar?
– Soft collar?
– No collar?
???????
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Pre-hospital
• Should this patient be clinically assessed and cleared at the scene? – How often does this occur?
– What are the problems of using it in the field?
– What is the miss rate?
????????
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Arrives in ED
• What sort of bed?
• What level of immobilisation?
• What sort of collar?
• How to clear?
???????
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Time to Wrap Up
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The Future?
Early Clinical Assessment Combined Protocol
Clinically cleared or cleared after assessment and adjunctive imaging
Long term comfort collar if fracture or neurology
ED
ASNSW & ED
ED
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You decide !
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So how do I do it?
• Combine NEXUS with CCR
– NEXUS clinical bedside exam
– CCR high and low risk features plus exclusions
– CCR range of movement plus pain on movement
– Plus bedside functional observation
• Lets run through that………
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Steps to Clinical Clearance
• Initial Primary Survey ABCDEs
• Cervical Spine Assessment Steps
1. Initial clinical examination
2. Historical risk factor assessment
3. Range of movement assessment
4. Functional assessment
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Cervical Spine Assessment
• Step 1 - Initial clinical examination
• Step 2 - Historical risk factor assessment
• Step 3 - Range of movement assessment
• Step 4 - Functional assessment
If patient fails any of these steps then will need medical imaging and further clinical assessment
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Initial Clinical Examination
• Alert conscious cooperative
• No drug or alcohol intoxication (nb analgesia)
• No painful distracting injury (nb analgesia)
• Neurologically normal on Hx & Ex (nb paresthesia)
• No midline bony tenderness on palpation
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History – High Risk
• Age > 65
• Pre-existing abnormal c-spine • Age >65
• Rheumatoid arthritis / ankylosing spondylitis
• Previous c-spine injury or surgery
• Dangerous mechanism • High speed MVA / rollover / ejection
• Fall from a height / down stairs / diving into surf
• High impact MBA / bicycle / pedestrian etc
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History – Low Risk
• Healthy young adult
• Walked since accident
• Delayed onset neck pain
• Simple rear end MVA
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Risk Factor Judgment
• Need to make a clinical judgment about the relative significance of the risk factors in light of the initial clinical examination
• Ask yourself - is it safe to assess neck movement?
• A young man who has fallen from a horse or bike is potentially high risk but if they subsequently walked at the scene they have already had a trial of neck movement so it is realistically safe to do a careful clinical examination.
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Range of Movement
• Assess range of neck movement if reassuring initial clinical examination and favourable risk factor profile
• Able to actively rotate neck 45* to left and right without restriction or significant midline neck pain?
• Able to flex and extend neck without restriction or significant midline neck pain?
Note the ability of patient to actively rotate neck 45* to left or right regardless of neck pain was most predictive
of lack of c-spine injury in the CCR
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Functional Assessment
• Remove collar
• Provide simple analgesics (paracetamol/ibuprofen)
• Observe & reassess
• Patients normally feel much better and start to move neck especially when distracted by family / friends
• Confirms clinical clearance
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Pitfalls
• Age > 65
• Analgesia / alcohol / alertness
• Unstable patients / multi-trauma
• Paresthesia
• Pain on movement
• Unexpected abnormal cspines
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C-Spine Clinical Clearance
• Step 1 - Initial clinical examination
• Step 2 - Historical risk factor assessment
• Step 3 - Range of movement assessment
• Step 4 - Functional assessment
If patient fails any of these steps then will need medical imaging and further clinical assessment