Issue
Ventilated trauma patient
- most will have CT scan
- doesn't exclude ligamentous injury
Hard collar
- will cause neck ulcers if left on indefinitely (occiput and jaw)
- raises the ICP / issue in head injured patient
Options
1. MRI
- sensitive but difficult especially in unwell, ventilated patient
- patients become more unstable being take to MRI
- ICP tend to rise (problem in head injuries)
- may increase time that cervical collar is left on
2. Flexion / extension views of unconscious patient
- under fluroscopy
- is this safe in the ventilated patient?
- has been shown to be very safe
- only very occasionally detects unstable injury missed by CT
- however, difficult to defend if patient wakes up with neurology
3. CT scan alone
- reported incidence of missed unstable C spine injury is 2.5%
Evidence
Spiteri et al J Trauma Infection and Critical Care 2006
- 839 ventilated trauma patients
- protocol of radiographs, helical CT and dynamic screening
- 87 unstable C spine injuries
- helical CT picked up 85
- dynamic screening picked up 1
- dynamic screening missed one atlanto-occipital dislocation
- a powers ratio on the CT would have detected this
- their conclusion was that helical CT was sufficient
Stelfox et al J Trauma Infection and Critical Care 2007
- 140 patients
- cervical collar removed if MRI or helical CT C0 - T1 normal
- policy changed to CT only
- no report of missed injury
- MRI patients waited longer, more likely to get ulcers, were ventilated longer