CICM SAQ 2013.2 Q11

Questions

A 28-year-old male has been involved in a high-speed motor vehicle crash and admitted to your hospital. His initial GCS at the scene was 5 (E2, V2, M1). He has been intubated and has a hard collar in place.

  • a) Outline your approach to clearing the cervical spine in this man. Justify your answer.
  • b) List the potential problems associated with the inability to clear the cervical spine at an early stage.

Answers

Answer and interpretation

a) Outline your approach to clearing the cervical spine in this man. Justify your answer.

The patient is sedated and so the cervical spine cannot be cleared clinically so will keep collar in place. Also check correct size and fitting.

  • Radiological clearance
  • Plain C-spine films are no longer suggested as routine part of trauma series but fractures on CXR and pelvic XR associated with increased risk of C-spine injury
  • High resolution 64 slice helical CT of the entire cervical spine and T1 with sagittal and coronal reconstructions
  • Review with radiologist
  • With technically adequate studies and experienced interpretation, the combination of multi-slice helical CT with reconstruction CT scanning provides a false negative rate of < 0.1%
  •  Clear radiologically and if low risk for ligamentous injury and patient unlikely to be extubated in 24-48 hr, remove collar.

Or:

  • If no bony injury but need to exclude ligamentous injury, perform MRI.
  • There is no 100% accurate method to exclude C-spine injury and management is a balance of risk-benefit for that individual.
  • In some cases clearing the C-spine early may not be possible and leaving the collar in situ is a balance between management of potentially “unstable” C-spine and the risk of complications from the collar.

b) List the potential problems associated with the inability to clear the cervical spine at an early stage.

  • Prolonged immobilization is associated with significant morbidity
  • Decubitus ulceration (especially related to cervical collar)
  • Increased need for sedation
  • Delayed weaning from respiratory support
  • Delays in percutaneous tracheostomy
  • Central venous access difficulties
  • Enteral feeding intolerance due to supine positioning
  • Pulmonary aspiration due to supine position
  • DVT due to prolongation of immobility
  • Increased risk of cross-infection due to extra staff / equipment involved in position
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Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

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