CT c-spine clears intoxicated patients

Short Attention Span Summary

In the era of modern CT scanners, do we need to keep the rigid c-collar on after CT c-spine is negative in intoxicated patients?  This study suggests the answer to that is no.  C-spine CT had a "negative predictive value of 99.8% for ruling out CSIs that required immobilization or stabilization."  Only 1 patient in 632 "had a symptomatic unstable ligament injury that was misread as normal on CT scan but was abnormal on magnetic resonance imaging."  My thoughts are that in patients with no gross motor deficits and normal c-spine CT, it is safe to remove the collar, even if intoxicated.  This is a major paradigm change and a topic that needs to be discussed and debated.  Would you comment on the EM Topics Facebook Page or participate in this poll?  Honestly, this makes me nervous but I think the data backs me up?  Other than Journal Watch, am I alone?

HEFT EM did a podcast on c-spine clearance in December.


Abstract

JAMA Surg. 2016 Jun 15. doi: 10.1001/jamasurg.2016.1248. [Epub ahead of print]

Evaluation of Cervical Spine Clearance by Computed Tomographic Scan Alone in Intoxicated Patients With Blunt Trauma.

Bush L1, Brookshire R1, Roche B1, Johnson A1, Cole F1, Karmy-Jones R1, Long W1, Martin MJ2.

Author information:

1Trauma and Acute Care Surgery Service, Legacy Emanuel Medical Center, Portland, Oregon.

2Trauma and Acute Care Surgery Service, Legacy Emanuel Medical Center, Portland, Oregon2Department of Surgery, Madigan Army Medical Center, Tacoma, Washington.

Abstract

Importance:

Current trauma guidelines dictate that the cervical spine should not be cleared in intoxicated patients, resulting in prolonged immobilization or additional imaging. Modern computed tomography (CT) technology may obviate this and allow for immediate clearance.

Objective:

To analyze cervical spine clearance practices and the utility of CT scans of the cervical spine in intoxicated patients with blunt trauma.

Design, Setting, and Participants:

We performed a prospective observational study of 1668 patients with blunt trauma aged 18 years and older who underwent cervical spine CT scans from March 2014 to March 2015 at an American College of Surgeons-verified Level I trauma center. Intoxication was determined by serum alcohol levels and urine drug screens. Physical examination and CT scan findings were evaluated for cervical spine injuries (CSI) and the incidence of missed injuries.

Main Outcomes and Measures:

Clinically relevant CSIs requiring cervical stabilization. The hypotheses formed prior to data collection were that cervical CT scans are sensitive and specific enough to diagnose CSIs that require stabilization and that normal CT scans are sufficient to clear CSIs in intoxicated patients.

Results:

Of 1668 patients, 1103 (66.1%) were male, with a mean (SD) age of 49 (20) years and a mean (SD) Injury Severity Score of 10 (9). Vehicular (734 [44.0%]) and falls (579 [34.7%]) were the most common mechanisms for hospitalization. Intoxication was identified in 632 of 1429 of patients tested (44.2%; 425 [29.7%] by serum alcohol levels and 350 [24.5%] by urine drug screens). Half (316 [50.0%]) were admitted with cervical spine immobilization, and 38 (12%) of these were solely owing to the presence of intoxication. There were 65 abnormal CT scans (10.3%) in the intoxicated group. Among 567 normal CT scans, 4 (0.7%) had central cord syndrome found on initial physical examination, and 1 (0.2%) had a symptomatic unstable ligament injury that was misread as normal on CT scan but was abnormal on magnetic resonance imaging. The 316 patients kept in a cervical collar for intoxication had no missed CSIs but were kept immobilized for a mean (SD) of 12 (19) hours. Computed tomographic scans had an overall negative predictive value of 99.2% for patients with CSIs and a negative predictive value of 99.8% for ruling out CSIs that required immobilization or stabilization.

Conclusions and Relevance:

In this study, alcohol or drug intoxication was common and resulted in significant delays to cervical spine clearance. Computed tomographic scans were highly reliable for identifying all clinically significant CSIs. Spine clearance based on a normal CT scan among intoxicated patients with no gross motor deficits appears to be safe and avoids prolonged and unnecessary immobilization.

PMID: 27305663 [PubMed - as supplied by publisher]

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