1 / 78

Clearing the cervical spine

Clearing the cervical spine. Dr Claudia AY Cheng Senior Medical Officer Department of Anaesthesia and Intensive Care. Objectives. Spinal immobilization and airway management Reading cervical spine X-rays Guidelines on clearing the cervical spine Cases.

garren
Download Presentation

Clearing the cervical spine

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Clearing the cervical spine Dr Claudia AY Cheng Senior Medical Officer Department of Anaesthesia and Intensive Care

  2. Objectives • Spinal immobilization and airway management • Reading cervical spine X-rays • Guidelines on clearing the cervical spine • Cases

  3. “Spinal immobilization is a priority in multiple trauma, spinal clearance is not”

  4. Who needs spinal immobilization? • All at risk patients: • Blunt injury • All patients with sufficient mechanism of injury to lead to a spinal injury should be considered to have a spinal injury until proven otherwise • What constitutes “sufficient mechanism” remains unclear • Penetrating injury • Gunshot wounds to the spinal column – necessary • Gunshot wounds to head and stab wounds – probably not necessary

  5. Vandemark criteria for high-risk patients • High velocity blunt trauma • Multiple fractures • Evidence of direct cervical injury (cervical pain, spasm, obvious deformity) • Altered mental status (LOC, alcohol/drug use) • Drowning or diving accident • Fall of > 10 feet • Significant head or facial injury • Thoracic or lumbar fracture • Rigid vertebral disease (AS) • Parasthesias or burning in extremities

  6. Spinal immobilization • Whole spine immobilisation is required • Neutral position • Firm surface • Can be achieved manually or with semi-rigid cervical collar, spinal board • Anaesthesia

  7. Neck Collars

  8. Moving the patient

  9. Spinal Board

  10. Airway management

  11. Airway obstruction

  12. Open airway - Head tilt-chin lift • Pulls the base of the tongue away from the back of the throat • Only perform if there is no possibility of cervical spine injury

  13. Airway management • Jaw thrust • Manual in-line immobilization • Oro- or naso-pharyngeal airways • Intubation with rapid sequence induction with cricoid pressure • Fibreoptic intubation • Laryngeal mask airway • Tracheostomy

  14. Open airway - Jaw thrust • Use the jaw thrust technique in patients with cervical spine injuries

  15. Manual in-line immobilization

  16. Oropharyngeal airway

  17. Nasopharyngeal airway

  18. Fibreoptic intubation

  19. Laryngeal Mask Airway –“LMA”

  20. How many plain X-rays are necessary? • Note: there is no statistically valid prospective or retrospective study addressing the issue of how many plain X-rays are necessary • Experts have different opinions • Time-consuming if many views. Open-mouth view most commonly repeated. Radiation exposure, cost • CT scan quicker (eg 6-view series = 22 minutes vs CT = 12 minutes) • CT more and more important as a screening tool; but cannot completely abandon plain x-ray series

  21. Plain X-rays • 3 views necessary: • Lateral: occiput to top of T1 • AP: spinous process of C2-C7 • Open mouth – entire dens and lateral masses of C1 • Sensitivity 92-99% • If lateral only: • Sensitivity 82-85%

  22. Flexion/extension views • Not helpful except for ensuring that minor degrees of anterolisthesis or retrolisthesis in patients with cervical spondylosis are fixed deformities • Muscle spasm in acute stage precludes adequate examination • It’s use is whether patient has ligamentous instability • MRI is procedure of choice

  23. Role of MRI • Reserve for patients with clear-cut neurologic findings • Patients with suspected ligamentous instability • Us as screen for multiple noncontiguous injuries (occurs in about 20% of patients)

  24. 3 views Lateral AP Open mouth

  25. 3 imaginary columns Anterior vertebral line Posterior vertebral line Spinolaminar line Disruption of more than one column = unstable injury

  26. Soft tissue shadow Above C4: , 50% width of vertebral body. Pharyngeal and prevertebral tissues Below C4: 1 full vertebral body width. Posterior larynx and oesophagus thickening Does not apply to intubated patients; invariably associated with soft tissue swelling

  27. Intubated patients; Invariably will have soft tissue swelling. Cannot interpret accurately

  28. Open mouth view Must see the lateral masses of C1 Odontoid peg

  29. Odontoid peg Atlanto-Dens Interval in adults < 3mm Upper c-spine distances Occiput-Atlas < 5 mm C1-C2 interspinous space <+ 10 mm

  30. NTEC/PWH Trauma Advisory CommitteeGuidelines for Cervical Spine Clearance

  31. Injury mechanism having the potential for causing a C-spine injury Immobilization YES E Altered mental status / intoxicated No YES D Neurological deficit No YES C Spinal pain or palpation tenderness No YES B A distracting painful injury No Clearing of C-spine clinically clear documentation A Satisfactory Off immobilization declare C-spine is clear Management flow chart for cervical spine clearance

  32. Can you clear the cervical spine without performing any X-rays?

  33. A C spine can be cleared if ALL conditions listed below are satisfied • Alert, not intoxicated • No neurological symptom or sign • No midline neck pain or tenderness (needs removal of immobilization device temporarily, but continue to keep in-line immobilization manually) • Painless, full range of motion – have the patient actively flex and rotate his/her neck with instructions to stop immediately should pain or paraesthesia develop • Absence of a distracting painful injury (eg. long bone extremity fracture)  Cervical spine X-rays NOT necessary

  34. Can you clear the cervical spine without performing any X-rays? YES

  35. Injury mechanism having the potential for causing a C-spine injury Immobilization Altered mental status / intoxicated No Neurological deficit No Spinal pain or palpation tenderness No A distracting painful injury No Clearing of C-spine clinically clear documentation A Satisfactory Off immobilization declare C-spine is clear

  36. How to clear the cervical spine if patient has a painful, distracting injury somewhere in the body?

  37. B Presence of a painful distracting injury, patient is fully conscious & alert, no symptom or sign referring to the cervical spine • Perform 3 views cervical spine X-rays • Failure to visualize the entire C spine will mandate additional studies eg. swimmer’s view or CT scan • Make sure clinical examination is done & documented If negative, cervical spine cleared

  38. Injury mechanism having the potential for causing a C-spine injury Injury mechanism having the potential for causing a C-spine injury Immobilization Immobilization YES E Altered metal status / intoxicated Altered mental status / intoxicated No No YES D Neurological deficit Neurological deficit No No YES C Spinal pain or palpation tenderness Spinal pain or palpation tenderness No No YES YES B B A distracting painful injury A distracting painful injury No Clearing of C-spine clinically clear documentation A Satisfactory Off immobilization declare C-spine is clear Off immobilization declare C-spine is clear

  39. How to clear the cervical spine if patient has pain on palpation of the cervical spine?

  40. C Patient is fully conscious & alert, complaining of neck pain or tenderness on palpation • 3 views C spine X rays • Axial CT at 3 mm intervals thru’ suspicious areas identified on these X rays • If lower C spine not adequately visualized, consider • Swimmer’s view • Axial CT at 3 mm intervals through lower C spine with sagittal reconstruction • If X-rays are normal, movement unrestricted and mild to moderate pain only, there is no need to perform any further investigations • For patient suspected to have significant c-spine injury, obtain flexion & extension views: • Voluntary & painless excursion must exceed 300 C spine cleared if no abnormality found • If voluntary, painless excursion does NOT exceed 300, neck collar is replaced and repeat X-rays in 2 weeks

  41. Injury mechanism having the potential for causing a C-spine injury Injury mechanism having the potential for causing a C-spine injury Immobilization Immobilization YES E Altered mental status / intoxicated Altered metal status / intoxicated No No YES D Neurological deficit Neurological deficit No No YES YES C C Spinal pain or palpation tenderness Spinal pain or palpation tenderness No YES B A distracting painful injury No Clearing of C-spine clinically clear documentation A Satisfactory Off immobilization declare C-spine is clear Off immobilization declare C-spine is clear

  42. D Presence of neurological deficits compatible with a spinal cord injury • 3 views X rays and supplemented by axial CT as necessary • MRI cervical spine • Manage according to the injury High dose methylprednisolone started within 8 hours of injury shown to improve outcome (30 mg/kg bolus, followed by 5.4 mg/kg infusion over the next 23 hours)

  43. Injury mechanism having the potential for causing a C-spine injury Injury mechanism having the potential for causing a C-spine injury Immobilization Immobilization YES E Altered metal status / intoxicated Altered metal status / intoxicated No No YES YES D D Neurological deficit Neurological deficit No YES C Spinal pain or palpation tenderness No YES B A distracting painful injury No Clearing of C-spine clinically clear documentation A Satisfactory Off immobilization declare C-spine is clear Off immobilization declare C-spine is clear

  44. Injury mechanism having the potential for causing a C-spine injury Injury mechanism having the potential for causing a C-spine injury Immobilization Immobilization YES YES E E Altered mental status / intoxicated Altered metal status / intoxicated No YES D Neurological deficit No YES C Spinal pain or palpation tenderness No YES B A distracting painful injury No Clearing of C-spine clinically clear documentation A Satisfactory Off immobilization declare C-spine is clear Off immobilization declare C-spine is clear

  45. How to clear the cervical spine if patient has altered mental status that affects neuro assessment?<24 hours > 24 hours

  46. If mental status is expected to return within 24 hours • Leave collar on and reassess when mental status returns or at 24 hours (whichever is earlier) • After patient regain consciousness • Consider flexion-extension cervical X-ray if there are symptoms related to the neck despite normal radiological examination • If there is pain and muscle spasm, flexion-extension cervical X-ray may be delayed for 2 weeks

  47. If mental status is expected to return within 24 hours • For MRI spine if neurological signs detected • Cervical spine is cleared if no signs and symptoms related to cervical spine

More Related