Harkness Deborah - Księga Wszystkich Dusz 01 - Czarownica.pdf
THE CERVICAL SPINE IN THE OBTUNDED PATIENT Lisa Harkness- Adult NP Trauma
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Transcript of 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
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• Cervical spine injuries occur frequently after major trauma
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SAFE AND PROMPT CERVICAL SPINECLEARANCE
• Sequelae of not clearing cervical spine safely and promptly is enormous
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......
SPINE BOARDS ?
• Good for pre hospital transport only –complications
SAFE AND PROMPT CERVICAL SPINE CLEARANCE
• Improperly clearing and missing injuries.....• Potentially devastating
HOW ?
• CLINICAL CLEARANCE OR IMAGING
• IMAGING – What /When ?• Plain x-rays• CT scans• MR• Flex Ex
HOW?
• CLINICAL CLEARANCE ALONE ?
HOW?
• CLINICAL CLEARANCE ALONE ?
IMAGING
• Who needs imaging
• When do we do Xrays vs CT vs MR
• How significant is a ligamentous injury
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
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
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.
IMAGING -XRAYS
• XRAYS – provide no additional info and miss injuries compared to CT
IMAGING – FLEX-EX
• RECENT STUDIES?
• No class 1 or 2 evidence• Anecdotal reports only• Majority – no additional info over CT
IMAGING – FLEX -EX
• Flex –ex -no additional information over CT
IMAGING -CT
• CT cross sectional images • Sensitive for finding fractures – 98 %• CT Cspine radiation? 1 : 10000 Cancer
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?
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%
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
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!
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
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
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
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
CONCLUSIONS
• Flex-Ex – no additional info over CT/case reports only
• Abnormal CT – consult• Neuro findings – consult• N CT and N MR - cleared
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
LHSC TRAUMA
NEGATIVE CT does NOT equal cleared at LHSC at present