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Cervical Spine TraumaCervical Spine TraumaDr. Martin Leahy PGYDr. Martin Leahy PGY--11
Dr.Norah DugganDr.Norah Duggan -- FacultyFaculty
Cervical Spine Trauma
Dr. Martin Leahy PGY-1
Dr. Norah Duggan
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IntroductionIntroduction
The diagnosis of an unstable spinal injuryThe diagnosis of an unstable spinal injury
and its subsequent management can beand its subsequent management can be
difficultdifficult
A missed spinal injury can have devastatingA missed spinal injury can have devastating
long term consequenceslong term consequences
As such, spinal column injury mustAs such, spinal column injury must
therefore be presumed until it is excludedtherefore be presumed until it is excluded
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Missed or delayed diagnosis most oftenMissed or delayed diagnosis most often
attributed to failure to suspect cervicalattributed to failure to suspect cervicalinjury, inadequate radiology, or incorrectinjury, inadequate radiology, or incorrect
interpretation of radiographsinterpretation of radiographs
As such, guidelines are needed to maximizeAs such, guidelines are needed to maximize
sensitivity and efficiency for the evaluationsensitivity and efficiency for the evaluation
of potentially unstable spine injuriesof potentially unstable spine injuries
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Primary concerns with cervical spinePrimary concerns with cervical spine
trauma include safe and effective clinicaltrauma include safe and effective clinicalclearance, the appropriate use of plain films,clearance, the appropriate use of plain films,
and when additional imaging such as CT orand when additional imaging such as CT or
MRI
should be used.MRI
should be used.
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Spinal stabilization andSpinal stabilization and
managementmanagement All patients with sufficient mechanism ofAll patients with sufficient mechanism of
injury to lead to a spinal injury should beinjury to lead to a spinal injury should be
considered to have a spinal injury untilconsidered to have a spinal injury untilproven otherwiseproven otherwise
What exactly constitutes sufficientWhat exactly constitutes sufficient
mechanism is undefinedmechanism is undefined
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Techniques of immobilisation andTechniques of immobilisation and
patient handlingpatient handling
Protect spine at all times during the managementProtect spine at all times during the managementof the multiply injured patient.of the multiply injured patient.
Up to 5% of spinal injuries have a second,Up to 5% of spinal injuries have a second,
possibly non adjacent, fracture elsewhere in thepossibly non adjacent, fracture elsewhere in thespinespine
Ideally, whole spine immobilised in neutralIdeally, whole spine immobilised in neutralposition on firm surface.position on firm surface.
Can be done manually or with a combination ofCan be done manually or with a combination ofsemisemi--rigid cervical collar, side head supports andrigid cervical collar, side head supports andstrappingstrapping
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Immobilisation in the pre hospital settingImmobilisation in the pre hospital setting
Application of definitiveApplication of definitiveimmobilisation devicesimmobilisation devicesshouldshould notnot taketake
precedence over lifeprecedence over life
saving proceduressaving procedures If neck not in the neutralIf neck not in the neutral
position, attempt shouldposition, attempt shouldbe made to achievebe made to achievealignment.alignment.
If the patient awake andIf the patient awake andcooperative, encourage tocooperative, encourage toactively move their neckactively move their neckinto lineinto line
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Abandon procedure ifAbandon procedure if
pain neurologicalpain neurological
deterioration ordeterioration or
resistance toresistance tomovementmovement
Long spine boards areLong spine boards are
valuable primarily forvaluable primarily for
extrication fromextrication from
vehicles.vehicles.
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Immobilisation in hospitalImmobilisation in hospital
Remove spine board as soon as possibleRemove spine board as soon as possible
once patient is on a firm stretcheronce patient is on a firm stretcher
Full immobilisation, however, should beFull immobilisation, however, should bemaintained and manual protection should bemaintained and manual protection should be
reinstated if restraints have to be removedreinstated if restraints have to be removed
for examination or procedures (eg.for examination or procedures (eg.
intubation)intubation)
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Log roll is standard manoeuver to allowLog roll is standard manoeuver to allow
examination of the back and patient transferexamination of the back and patient transfer
Optimally, four people are required, forOptimally, four people are required, for
head chest pelvis and limbshead chest pelvis and limbs
Rigid transfer slides are useful forRigid transfer slides are useful fortransferring the patient from one surface totransferring the patient from one surface to
another (eg. to CT scanner)another (eg. to CT scanner)
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Agitation, shock, restlessness, orAgitation, shock, restlessness, or
intoxication may make adequateintoxication may make adequateimmobolization impossibleimmobolization impossible
In these situatuions, forced restraints orIn these situatuions, forced restraints or
manual fixation of the head may risk furthermanual fixation of the head may risk furtherinjury to the spineinjury to the spine
Consider removing immobilisation devicesConsider removing immobilisation devices
allowing the patient to move unhinderedallowing the patient to move unhindered
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Clinical Clearance of CervicalClinical Clearance of Cervical
SpineInjurySpineInjury
Key PointsKey Points
1. Spinal immobilisation is a priority in multiple1. Spinal immobilisation is a priority in multipletrauma, spinal clearance is nottrauma, spinal clearance is not
2. The spine should be assessed and cleared when2. The spine should be assessed and cleared whenappropriate, given the injury characteristics andappropriate, given the injury characteristics andphysiological statephysiological state
3. Imaging the spine does not take precedence3. Imaging the spine does not take precedenceover life saving diagnostic and therapeuticover life saving diagnostic and therapeuticproceduresprocedures
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Numerous large prospectiveNumerous large prospectivestudies have described the largestudies have described the large
cost and low yield of thecost and low yield of the
indiscriminate use of cindiscriminate use of c--spinespine
radiology in trauma patientsradiology in trauma patients
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Two recent papers haveTwo recent papers have
attempted to address this questionattempted to address this question
NEXUSNEXUS --The National Emergency XThe National Emergency X--
Radiograph Utilization StudyRadiograph Utilization Study
This was a prospective study put forth toThis was a prospective study put forth to
validate a rule for the decision whether to xvalidate a rule for the decision whether to x--ray in low risk patientsray in low risk patients
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Criteria were as follows..Criteria were as follows..
1. Absence of tenderness in the posterior1. Absence of tenderness in the posterior
midlinemidline
2. Absence of a neurological deficit2. Absence of a neurological deficit 3. Normal level of alertness (GCS15)3. Normal level of alertness (GCS15)
4. No evidence of intoxication4. No evidence of intoxication
5. No distracting pain elsewhere5. No distracting pain elsewhere
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Any patient who fulfilled all 5 of theAny patient who fulfilled all 5 of the
aforementioned criteria were consideredaforementioned criteria were considered
low risk for Clow risk for C--spine injury and as such didspine injury and as such didnot receive Cnot receive C--spine radiographyspine radiography
For patients who had any of the 5 criteria,For patients who had any of the 5 criteria,
radiographic imaging was deemed indicatedradiographic imaging was deemed indicated
in the form of AP, lateral, and odontoid Cin the form of AP, lateral, and odontoid C--
spine viewsspine views
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Results of NEXUS studyResults of NEXUS study
34069 patients were enrolled34069 patients were enrolled
818 had significant C818 had significant C--spine injuryspine injury
810 were identified as potential spinal810 were identified as potential spinalinjury patients by the decision ruleinjury patients by the decision rule
8 patients were identified as low risk but in8 patients were identified as low risk but in
fact had radiographic injuryfact had radiographic injury
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Sensitivity 99%Sensitivity 99%Negative predictive value 99.8%Negative predictive value 99.8%
Specificity 12.9%Specificity 12.9%
Positive predictive value 2.7%Positive predictive value 2.7%
Study was well receivedStudy was well received
But..some felt criteria to be tooBut..some felt criteria to be too
ambiguous and open to interpretationambiguous and open to interpretation
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Canadian CCanadian C--Spine RulesSpine Rules
Prospective study whereby patients wereProspective study whereby patients were
evaluated for 20 standardized clinicalevaluated for 20 standardized clinical
findings as a basis for formulating afindings as a basis for formulating a
decision as to the need for subsequentdecision as to the need for subsequent
radiographyradiography
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Rules were as follows..Rules were as follows..
1. Was there any high risk factor that1. Was there any high risk factor that
mandates radiography?mandates radiography?
Includes age>65, dangerous mechanism ofIncludes age>65, dangerous mechanism ofinjury, and presence of paraesthesiasinjury, and presence of paraesthesias
If yes, XIf yes, X--rayray
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2. Were there any low risk factors that2. Were there any low risk factors that
allow some assessment of range ofallow some assessment of range ofmotion?motion?
Included simple rear end MVC, sittingIncluded simple rear end MVC, sitting
position in ER, ambulatory at any time,position in ER, ambulatory at any time,delayed onset of neck pain, and absence ofdelayed onset of neck pain, and absence of
midline cmidline c--spine tendernessspine tenderness
I
f none, need XI
f none, need X--rayray
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3. Was the patient actively able to move3. Was the patient actively able to move
their neck?their neck?
If yes, then no xIf yes, then no x--rayray
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Results of Canadian CResults of Canadian C--SpineSpine
StudyStudy 8924 patients enrolled8924 patients enrolled
100 % sensitivity for identifying 151100 % sensitivity for identifying 151clinically important Cclinically important C--spine injuriesspine injuries
42.5 % specificity42.5 % specificity
deemed a highly sensitive decision rule fordeemed a highly sensitive decision rule foruse of Cuse of C--spine radiography in alert andspine radiography in alert and
stable trauma patientsstable trauma patients
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Clearance of Cervical SpineClearance of Cervical Spine
Injury in Conscious,Injury in Conscious,Symptomatic PatientsSymptomatic Patients
Key PointsKey Points
1. Radiological evaluation of the cervical1. Radiological evaluation of the cervicalspine is indicated for all patients who do notspine is indicated for all patients who do notmeet the criteria for clinical clearance asmeet the criteria for clinical clearance asdescribed abovedescribed above
2. Imaging studies should be technically2. Imaging studies should be technicallyadequate and interpreted by experiencedadequate and interpreted by experiencedcliniciansclinicians
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Plain Film RadiologyPlain Film Radiology
The standard 3 view plain film series is theThe standard 3 view plain film series is thelateral, anterolateral, antero--posterior, and openposterior, and open--mouthmouthviewview
The lateral cervical spine film must includeThe lateral cervical spine film must includethe base of the occiput and the top of thethe base of the occiput and the top of thefirst thoracic vertebrafirst thoracic vertebra
The lateral view alone is inadequate andThe lateral view alone is inadequate andwill miss up to 15% of cervical spinewill miss up to 15% of cervical spineinjuries.injuries.
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If lower cervical spine difficult to see,If lower cervical spine difficult to see,
caudal traction on the arms may be usedcaudal traction on the arms may be used
to improve visualisationto improve visualisation
Repeated attempts at plain radiographyRepeated attempts at plain radiography
are usually unsuccessfulare usually unsuccessful
If the lower cervical spine is not visible,If the lower cervical spine is not visible,
a CT scan of the region is then indicateda CT scan of the region is then indicated
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How to read the Lateral CervicalHow to read the Lateral Cervical
Spine XSpine X--RayRay Lateral cervical spineLateral cervical spine
xx--ray must visualiseray must visualise
entire cervical spine .entire cervical spine .
A film that does notA film that does not
show the upper bordershow the upper border
of T1 is inadequateof T1 is inadequate
Caudal traction on theCaudal traction on the
arms may helparms may help
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The anterior vertebral line ,The anterior vertebral line ,
posterior vertebral line, andposterior vertebral line, and
spinolaminar line should havespinolaminar line should have
a smooth curve with no stepsa smooth curve with no steps
or discontinuitiesor discontinuities
Malalignment of the posteriorMalalignment of the posterior
vertebral bodies is morevertebral bodies is more
significant than that anteriorly,significant than that anteriorly,
which may be due to rotationwhich may be due to rotation
A step of >3.5mm isA step of >3.5mm is
significant anywheresignificant anywhere
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Anterior subluxation of oneAnterior subluxation of one
vertebra on another indicatesvertebra on another indicatesfacet dislocationfacet dislocation
Less than 50% of the widthLess than 50% of the width
of a vertebral body impliesof a vertebral body implies
unifacet dislocationunifacet dislocation
Greater than 50% impliesGreater than 50% implies
bilateral facet dislocationbilateral facet dislocation
This is usually accompaniedThis is usually accompanied
by widening of theby widening of the
interspinous and interlaminarinterspinous and interlaminar
spacesspaces
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Vertebral body andVertebral body andintervertebral discintervertebral disc
examination revealexamination revealcompression and burstcompression and bursttype injuriestype injuries
Bodies normally regularBodies normally regularcuboids similar in size andcuboids similar in size and
shape to the vertebraeshape to the vertebraeimmediately above andimmediately above and
below (not C1/C2)below (not C1/C2)
Anterior wedging ofAnterior wedging ofvertebral body or teardropvertebral body or teardrop
fractures of anterofractures of antero--inferiorinferiorportion of body impliesportion of body impliescompression fracturecompression fracture
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Anterior compression of greater than 40%Anterior compression of greater than 40%of normal vertebral body height indicates aof normal vertebral body height indicates a
burst fracture with retropulsion of fragmentsburst fracture with retropulsion of fragments
of the vertebral body into the spinal canalof the vertebral body into the spinal canal
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Loss of height of anLoss of height of anintervertebral discintervertebral discspace may indicatespace may indicatedisc herniationdisc herniation
Analysis ofAnalysis of
prevertebral softprevertebral softtissues may allow thetissues may allow thediagnosis of cervicaldiagnosis of cervicalinjuriesinjuries
Soft tissue shadow isSoft tissue shadow iscreated by pharyngealcreated by pharyngealand prevertebraland prevertebraltissuestissues
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AtlantoAtlanto occipital dissociationoccipital dissociation
AtlantoAtlanto--occipital dissociation can beoccipital dissociation can be
very difficult to diagnose and is easilyvery difficult to diagnose and is easily
missed.missed.
The distance from the occiput to theThe distance from the occiput to the
atlas should not exceed 5mm anywhereatlas should not exceed 5mm anywhere
on the filmon the film
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Odontoid peg must also beOdontoid peg must also be
examined for fracturesexamined for fractures Soft tissue swellingSoft tissue swelling
anterior to arch of C1anterior to arch of C1suggests fracture at thissuggests fracture at thislevel.level.
AtlantoAtlanto--Dens IntervalDens Interval(ADI) in adults should be(ADI) in adults should be 3.5mm impliesinjury to transverseinjury to transverse
ligament, and > 5mmligament, and > 5mmindicates complete ruptureindicates complete ruptureand instabilityand instability
C1C1--C2 interspinous spaceC2 interspinous spaceshould not be >10mmshould not be >10mm
widewide
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The AnteroThe Antero--Posterior ViewPosterior View
AnteroAntero--posteriorposterior
view must includeview must include
spinous processes ofspinous processes ofall cervical vertebraeall cervical vertebrae
from C2 to T1from C2 to T1
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The Open Mouth ViewThe Open Mouth View
The open mouth viewThe open mouth view
should visualise the lateralshould visualise the lateral
masses of C1 and themasses of C1 and the
entire odontoid peg.entire odontoid peg.
Bite blocks may improveBite blocks may improve
viewingviewing
In the unconscious,In the unconscious,
intubated patient the openintubated patient the open
mouth view is inadequatemouth view is inadequate
and occiput to C2 CTand occiput to C2 CT
scan recommendedscan recommended
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The addition of two oblique views toThe addition of two oblique views tothe standard 3 view series does notthe standard 3 view series does not
increase the sensitivity of plain filmincrease the sensitivity of plain film
evaluationevaluation
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CT ScanningCT Scanning
Thin cut CT scanningThin cut CT scanning
should be used to evaluateshould be used to evaluate
abnormal, suspicious orabnormal, suspicious or
poorly visualised areas onpoorly visualised areas on
plain radiologyplain radiology
The combination of plainThe combination of plain
radiology and directed CTradiology and directed CT
scanning provides a falsescanning provides a false
negative rate of less thannegative rate of less than0.1%0.1%
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MRIMRI
Ideally (ie. U.S.) all patients with anIdeally (ie. U.S.) all patients with anabnormal neurological examinationabnormal neurological examination
should be evaluated in a specialist unitshould be evaluated in a specialist unit
and have an MRI scan of the spineand have an MRI scan of the spine Patients who report transientPatients who report transient
neurological symptoms but who have aneurological symptoms but who have a
normal exam should also undergo annormal exam should also undergo anMRI assessment of their spinal cordMRI assessment of their spinal cord
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Radiographic Examination andRadiographic Examination and
Clearance of Cervical SpineInjuryClearance of Cervical SpineInjury --
Unconscious, Intubated PatientsUnconscious, Intubated Patients
K
ey PointsK
ey Points1. The odontoid view is unreliable in intubated1. The odontoid view is unreliable in intubated
patientspatients
2. Clinical examination is impossible in the2. Clinical examination is impossible in the
unconscious patientunconscious patient3. Plain film radiology cannot exclude3. Plain film radiology cannot exclude
ligamentous instabilityligamentous instability
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Standard radiological examination ofStandard radiological examination of
cervical spine in unconscious,cervical spine in unconscious,intubated patients isintubated patients is
1. Lateral cervical spine film1. Lateral cervical spine film
2. Antero2. Antero--posterior cervical spine filmposterior cervical spine film3. CT scan of occiput3. CT scan of occiput -- C3C3
The open mouth odontoid radiographThe open mouth odontoid radiographis inadequate in intubated patients andis inadequate in intubated patients andwill miss up to 17%of injuries to thewill miss up to 17%of injuries to the
upper cervical spineupper cervical spine
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Clearance of the spine in unconsciousClearance of the spine in unconscious
patients is limited by the lack ofpatients is limited by the lack ofclinical informationclinical information
Incidence of unstable spinal injury inIncidence of unstable spinal injury in
adult, intubated trauma patients isadult, intubated trauma patients is
about 10.2%about 10.2%
Incidence of unstable, occult spinalIncidence of unstable, occult spinal
trauma (not visible on plain films) istrauma (not visible on plain films) is
about 2.5%about 2.5%
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Unconscious patient .Unconscious patient .
Continue spinal precautions until fullyContinue spinal precautions until fullyconsciousconscious
If patient is expected to regain fullIf patient is expected to regain full
consciousness within 24consciousness within 24--48 hrs, patient48 hrs, patientcan be nursed with full spinalcan be nursed with full spinalprecautionsprecautions
Collar not necessary in adequatelyCollar not necessary in adequatelysedated, ventilated patient, and maysedated, ventilated patient, and mayincrease intracranial pressure inincrease intracranial pressure inpatients with traumatic brain injurypatients with traumatic brain injury
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Magnetic Resonance Imaging inMagnetic Resonance Imaging in
Unconscious CUnconscious C--Spine TraumaSpine Trauma Extremely sensitive at detecting soft tissueExtremely sensitive at detecting soft tissue
injuries without stressing cervical spineinjuries without stressing cervical spine--
SIGNIFICANCE??SIGNIFICANCE?? High false positive rateHigh false positive rate
Few good studies on the use of MRI inFew good studies on the use of MRI inclearing the cervical spine in unconsciousclearing the cervical spine in unconsciouspatientspatients
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CT ScanCT Scan Whole CWhole C--SpineSpine
Recent concept of full cervical spine CT forRecent concept of full cervical spine CT forassessment of spinal injury has emerged.assessment of spinal injury has emerged.
Several studies have demonstrated robustness ofSeveral studies have demonstrated robustness of
full CT scan for exclusion of significant spinalfull CT scan for exclusion of significant spinalinjuryinjury
When whole cervical spine CT scanning isWhen whole cervical spine CT scanning isperformed, anteroperformed, antero--posterior plain film becomesposterior plain film becomes
redundantredundant
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In any case, regardless of theIn any case, regardless of theinjury suspected, protectinjury suspected, protect
yourselfyourself
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Four Basic Reasons WhyFour Basic Reasons Why
Cervical Spine Fractures AreCervical Spine Fractures Are
Missed By ER PhysiciansMissed By ER Physicians
1. Failure to obtain indicated films1. Failure to obtain indicated films
2. Inadequate films2. Inadequate films
3. Misinterpretation of the films3. Misinterpretation of the films
4. Films fail to adequately visualize the4. Films fail to adequately visualize theinjuriesinjuries
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Excuses That Wont WorkInExcuses That Wont WorkIn
CourtCourt I felt the xI felt the x--ray wasray was
adequate even thoughadequate even thoughI couldnt see the C7I couldnt see the C7--
T1 areaT1 area Never settleNever settlefor inadequate films!for inadequate films!
I didnt immobilizeI didnt immobilize
his neck because hehis neck because hewas drunk andwas drunk anduncooperativeuncooperative
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I didnt think an openI didnt think an openfemur fracture wouldfemur fracture would
distract him fromdistract him fromreporting tenderness onreporting tenderness onhis neck examhis neck exam AnyAnydoubts of a distractingdoubts of a distractinginjury, order a Cinjury, order a C--spinespine
filmfilm
I wanted to get a lateral I wanted to get a lateralCC--spine film beforespine film beforeintubationI had no wayintubationI had no way
of knowing he wouldof knowing he wouldaspirate!aspirate! Dont hesitateDont hesitateto use oral endotrachealto use oral endotrachealintubation with cervicalintubation with cervicalimmobilization as it hasimmobilization as it has
been proven safebeen proven safe
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References
Mower W., Hoffman J., Pollock C, et al. Use of plain
radiography to screen for cervical spine injuries.Annals of
Emergency Medicine. 2001;38(1)
Brohi K. Initial assessment of spinal trauma. Trauma.
Org.2002;7 (4)
Steill I, Wells G, VandemheenK, et al. The Canadian C-
spine rule for radiography in alert and stable trauma
patients. JAMA. 2001 Oct 17; 286 (15): 1841-8.
Tintinalli J, Krome R, Ruiz R. Emergency Medicine. A
comprehensive study guide. 1992
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Thank YouThank You