Clearing Drunk C-spines

Spoon Feed
A negative c-spine CT had 99.9% NPV for clinically significant c-spine injury in intoxicated patients.  The Western Trauma Association recommends c-spine clearance of intoxicated patients if gross motor function is normal, no neurologic complaints, and negative c-spine CT per experienced radiologist.  Be careful out there, and get institutional buy-in if you plan to put this into practice.

Why does this matter?
Rigid c-spine immobilization is not benign, including increased aspiration risk, pressure ulceration, increased hospital-acquired pneumonia risk, increased DVT risk, increased intracranial pressure, and more.  Timely cervical collar clearance is important.  The NEXUS rule does not allow for clearance in intoxicated patients.  This study sheds more light on the safety of clearance in such patients.

I'm too sexy for my collar...
This was a large prospective study of over 10,000 patients with blunt trauma.  About 30% were intoxicated (...only 30%?).  In these patients, c-spine CT was 94% sensitive, 99.5% specific, and had 99.5% NPV for all c-spine injuries. For clinically significant injuries, NPV was 99.9% and 100% for unstable injuries. The only missed significant injury was a central cord syndrome without fracture or ligamentous injury.  Those who were intoxicated took an average of 8 hours to clear the collar vs. only 2 hours if not intoxicated.  One quarter of intoxicated patients took over 12 hours for collar clearance.  In short, the authors advocate for rigid collar clearance if CT is negative, even in intoxicated patients, provided the gross motor exam is normal.  They state, "We argue that this should include all patients that do not have a gross motor deficit or neurologic complaint at presentation, and in whom a modern high-quality CT scan interpreted by an experienced trauma radiologist has been performed and shows no concerning pathology." This WTA position is in agreement with the EAST guidelines. 

Source
Cervical spine evaluation and clearance in the intoxicated patient: a prospective western trauma association multi-institutional trial and survey.  J Trauma Acute Care Surg. 2017 Jul 19. doi: 10.1097/TA.0000000000001650. [Epub ahead of print]

Another Spoonful
Ryan Radecki has a helpful summary of this article.  If you haven't discvoered it yet, EM Lit of Note is a fantastic #FOAMed resource.

Peer reviewed by Thomas Davis, MD.

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