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Cervical Spine Clearance in the trauma patient

Although in ED we cannot prevent the primary injury, our objective is to recognise and prevent secondary injury. Through the use of the agreed standards

Standards:

  1. Spinal protection must remain in place if an injury is suspected/identified, or until it is excluded via an established protocol.
    • Unless a senior clinician has clearly documented a decision, immobilisation not in the patients best interest.
  2. Assessment of the whole spine should be performed and documented where injury is suspected.
  3. If abnormal clinical signs are found, complete neurological examination must be performed and documented.
  4. If spinal injury identified OR abnormal neurological signs consistent with spinal cord injury are found, immediate discussion with and referral to a centre capable of emergency spinal surgery must occur.
  5. Significant spinal injury is excluded following either:
    • Normal clinical examination in an awake and orientated patient with no clinically significant distracting injury OR illness is present; the patient can concentrate on and reliably report neck findings. (in line with Canadian C-Spine rules)
    • Completion of spinal imaging protocols (standard 6).
  6. Imaging protocols:
    • Thoracic and lumbar spine scans should be obtained according to major trauma protocols.If a cervical spine injury is suspected, thin slice CT scanning from occiput to T4, including sagittal and coronal reconstructions should be performed without delay.If whole-body CT (WBCT) for trauma is necessary, this should include the cervical spine if injury is suspected.
    • An initial report of spine clearance imaging should be available before the patient leaves the Emergency Department.
OptionScenarioAction
1This investigation demonstrates an injury that may affect spinal stability. (see Notes)Continue spinal protection and seek advice from an appropriate clinical team. 
2This scan is of good quality and there are no comorbidities confounding its interpretation. No features of instability, such as fracture, haematoma or joint disruption are seen.Patients with NO acute neurological symptoms/signs on examination or mobilisation.Spinal protection may be removed.
Patient who HAS acute neurological symptoms/signs on examination or mobilisation.Continue spinal protection and seek advice from an appropriate clinical team. 
Unconscious OR unable to Co-Operate with examination (see Notes)Spinal protection can be removed with caution providingConsultant Radiology report & No evidence of acute neurological deficitIt must be recognised there is a <1% chance of unrecognised injury. ANY evidence of neurological deterioration should be re-immobilised pending MRI
3Whilst there are no obvious features of spinal instability, the CT scan is either not of good quality and/or there are comorbidities confounding its interpretation.Continue spinal protection until MRI is performed and report available.

Magnetic Resonance Imaging is necessary when the following are present:

  • Suspected cord injury
  • Ambiguous CT scans, as per option 3 of standard 6
  • Inability to assess patient, as per option 2 standard 6 
  • Ankylosed spines with negative or indeterminate CT appearances for fracture
  • Contraindications to ionising radiation, for example in pregnancy

    Notes:

    • Option 1 Standard 6: Certain Spinal injuries may be combatable with removal of protection on agreement of the base speciality consultant:
      • Facet joint fractures of the thoracic and lumbar spine
      • Spinous process fractures
      • Wedge compression fracture with loss of vertebral body height of less than 25%
      • Type 1 odontoid fracture
      • End-plate fracture
      • Transverse process fracture
      • Trabecular bone injury
      • Osteophyte fracture, excluding corner or teardrop fractures
      • Isolated avulsion fractures
    • Option 2 Standard 6: Management of Unconscious or patients unable to fully co-operate with clinical exanimation is recognised as significant challenge. With advances in CT the number of significant injuries missed is very low <1%. However, there are significant risks associated with prolonged immobilisation, especially for frail patients who are more likely to fall into this group. 

    This pragmatic approach is in line with BOA-Standards, however, it must be recognised there is a chance of deterioration. If ANY evidence of neurological deficit the patient should be re-immobilised and reassessed for further imaging. 

    Complications of prolonged use of Immobilisation:

    • Impaired venous drainage and increased intracranial pressure
    • Difficult laryngoscopy and intubation
    • Increased risk of aspiration and ventilator-associated pneumonia
    • Difficult central venous cannula insertion
    • Increased risk of central venous cannula associated blood stream infections
    • Increased risk of pulmonary thromboembolism
    • Pressure necrosis leading to ulceration
    • Inability to provide good oral care
    • Failed enteral nutrition, gastrostasis and reflux
    • Restricted physiotherapy

    Reference:

    Medical Emergencies in Eating Disorders

    Eating disorders* are relatively common and unfortunately patients who “look well” can have a significant mortality risk. MEED.org.uk have national risk tools to recognise those that would benefit from admission, which fit with our local mental health teams, and agreed by both acute medicine and paediatrics

    (*anorexia nervosa, bulimia nervosa, binge eating or avoidant restrictive food intake disorder)

    Risk Assessment

    RED indicators

    Anyone with one or more RED’s is high risk and should be considered for admission MEED

    • BMI <13/<70% mBMI
    • Recent weight loss >1 kg/week for 2 weeks in an underweight patient
    • HR (awake) <40
    • Recurrent syncope with standing BP <90 systolic (<0.4th percentile for age) and postural drop >20 mmHg (or increase HR >30 [>35 if <16])
    • Fluid refusal or signs of dehydration
    • Temperature <35.5°C tympanic/35°C axillary
    • Long Qt or other ECG abnormalities
    • Low Glu/Na/K/Ca/PO4/Alb
    • Low WCC, Hb <10
    • Acute food refusal/very low calorie intake per day
    • Physical struggles with carers over nutrition
    • High levels of uncontrolled exercise (>2 hours/day)
    • Daily purging behaviours
    • Self-harm
    • Moderate–high risk suicidal ideas.
    MEED Check list

    Hip Dislocation – Flowchart

    Dislocation of a Native Hip

    • Uncommon – High-Energy injury
    • All patients presenting with a suspected native hip dislocation following trauma (including falls from standing) must have a primary survey done to assess for other injuries.
    • Early Senior input (if not trauma team) and Resus
    • Neurovascular status of the affected limb must be assessed and documented. 

    Dislocation of Prosthetic Hip

    • Relatively common and frequently low energy
    • All patients should be assessed with low threshold to treat as trauma
      • Remember the biggest cause of ISS >15 Major Trauma in UK is older patients falling from standing height
    • Neurovascular status of the affected limb must be assessed and documented. 
    • If there is neurovascular compromise then move to Resus and inform ED senior 
    Read more

    Clinical Expectations

    ED Tiers.

    Tier [Examples]Expectation
    1.
    [FY1]    		– Require direct supervision
    – At a minimum patient being admitted should be discussed with a more senior clinician (ideally Tier 3+), and reviewed in person by a senior clinician if being discharged (Tier 3+)
    2.
    [FY2-ST2]    		– Require reduced supervision compared to tier 1
    – Require access to on-site supervision but able to see some patients independently within a limited and agreed scope of practice
    – RCEM senior sign-off guidance appliesProgression of increasing responsibility and experience as per RCEM curriculum
    3. [ST3/SAS/ACP]-Senior doctors able to lead a department with remote supervision from a tier 5 doctor.Possess some extended skills that can be practiced independently. Full scope ofpractice
    – Progression of increasing responsibility and experience as per RCEM curriculum
    4.
    [ST4+, SAS]    		– Senior doctors able to lead a department with remote supervision from a tier 5 doctor.
    – Possess some extended skills that can be practiced independently.
    – Full scope of practice
    – Progression of increasing responsibility and experience as per RCEM curriculum
    5.
    [Consultant]    		– Senior doctors with a full set of extended skills and who have demonstrated their ability to take independent clinical responsibility for an ED
    – Reference point: RCEM curriculum

    Senior Reviews.

    The following require Consultant/Tier 4/PEM T3+ – Sign off

    • NEWS2 > 5
    • Atraumatic chest pain in patients aged 30 years and over
    • Fever in children under 1 year of age
    • Patients making an unscheduled return to the ED with the same condition within 72 hours of discharge
    • Abdominal pain in patients aged 70 years and over

    The review should be recorded in the patient’s clinical notes and should ideally include the patient being seen and reviewed in person by the EM Senior.

    Responsibility in ED – Trust Agreed

    The following principles have been agree by ALL: CD’s, DD’s and Medical Director, (as per GIRFT guidance)

    ED Clincial Responsibility Principles 03062024[56] copyDownload

    Consultant Expectations

    The following are the agreed expectation of consultant roles in ED

    Consultant expectationsDownload

    Swallowed Foriegn Body

    The ingestion of a foreign body or multiple foreign bodies (FB) is a common presenting complaint in paediatric surgery, with a peak incidence from 12-24 months however, can occur at any age. Ingested foreign bodies rarely cause problems; almost 80% of patients pass the foreign body without intervention – in seven days2 (only 1% require surgical removal). However, occasionally foreign bodies can cause significant morbidity (for example, oesophageal rupture) and 1% require surgical removal.

    The presenting symptoms and outcomes of an ingested foreign body is highly dependent on the swallowed object, and for this reason, the guidance for hazardous and non-hazardous foreign body ingestion has been divided accordingly.

    Using the Metal Detector

    Non-Hazardous Objects

    Button Battery

    Ingestion of Button Battery = POTENTIAL EMERGENCY

    See separate post for more resources and education if desired.

    Magnets

     

    Sharp Objects

    PDF copy – HERE