“CLEAR!”, “CLEAR!”
Aug 04, 2008 in Learn
Image via WikipediaClearing the C-spine in unconscious or obtunded patients has bugged (and buggered) trauma teams around the world for decades. Several guidlines have been published over the years on how to manage patients with potential C-spine injuries following blunt trauma (incidence about 5%, apparently). Unfortunately none of them is universally applicable.
The Eastern Association for Surgery in Trauma (EAST) has published guidelines for clearing the C-spine in awake/compliant patients on clinical grounds (without radiology), and these could previously be seen at the EAST website. However, since it appears to have been infected with a spyware virus (according to my Sophos and AVG scanners!), so rather than go through the front portal of the site, see them instead by following these direct links:
The National Emergency X-Radiography Utilization Study (NEXUS) Low Risk Criteria for C-Spine Injury and the Canadian C-spine rules also exist, and you can read about both of these in an article from the NEJM (free access) here., and also an article here.
One of the greatest difficulties, and most difficult questions to answer is: once there have been x-rays and possibly CT, or even MRI, when do we take the collar off? A recent article in the Continuing Education in Anaesthesia, Critical Care & Pain [2008 8(4):117-120] tries to put us out of our misery by publishing a suggested flow chart for clearing the c-spine in an unconscious patient, and also shoves it right up on the agenda for SAQ/Viva potential.
It is difficult to decide what kind of question might come out of this, but potentially:
- Describe potential causes of neurological defecit in a patient who has fallen from more than 10 metres (30 feet)?
- How would you assess the cervical spine for injury in a patient with a Glasgow Coma Scale score of 10 or less?
Alternatively:
- What are the advantages and disadvantages of spinal immobilisation in an unconscious patient?
- How can you determine the requirement for continued immobilisation?
This is a common problem that we will all see and have to deal with, and therefore is fair game…
