Evaluation and Initial Management of Potential Traumatic Spinal Injuries

Transcription

1 Evaluation and Initial Management of Potential Traumatic Spinal Injuries Reference Number: NHSCT/10/268 Responsible Directorate: Acute Hospital Services Replaces (if appropriate): N/A Policy Author/Team: Critical Care Network Northern Ireland (CCaNNI) including representation from the Northern Health and Social Care Trust, ie, Director of Acute Hospital Services, Clinical Lead for Critical Care, Lead Nurse and General Manager for Critical Care Approved by: Policy, Standards and Guidelines Committee Type of document: Directorate Guideline Date Policy disseminated by the Policy Unit: 1 April 2010 Date Approved: February 2010 NHSCT Mission Statement To provide for all the quality of services we would expect for our families and ourselves - 1 -

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3 Evaluation and Initial Management of Potential Traumatic Spinal Injuries Guideline (Adopted CCaNNI Guideline) - 3 -

4 GUIDELINE EVALUATION AND INITIAL MANAGEMENT OF POTENTIAL TRAUMATIC SPINAL INJURIES 1. The purpose/objective of the standard/guideline Optimal investigation and protection of potentially unstable spine in trauma patients balanced against risk of prolonged use of spinal immobilisation. 2. Intended target population Patients suffering traumatic injury or high energy mechanical forces 3. Methods used to collect and select evidence Process and sources used by Royal Victoria Hospital Belfast and Northern Ireland Intensive Care Society 4. Sources of information used in development of standard/guideline As above 5. Assessment of the strength of the evidence (using a rating scheme) As above 6. Method used to formulate recommendations As above 7. Recommendations CCaNNI PS&G accept recommendations with minor modifications to layout and enhanced use of CT scanning. 8. Cost analysis (& timescale for implementation) At this point not relevant to CCaNNI PS&G 9. Qualifying statements CCaNNI has not developed this guideline. The Policy Standards & Guidelines sub committee of CCaNNI has reviewed the guideline developed by others which it believes to be relevant and applicable, and has modified it to facilitate clarity and to make use of developments in provision of CT technology. 10. Date of issue April Date for review April Composition of group authoring standard/guideline Royal Victoria Hospital Belfast (now part of Belfast HSC Trust). 13. Financial disclosures/conflicts of interest None - 4 -

5 Guidelines for evaluation & initial management of potential traumatic spinal injuries GROUP 1 PATIENTS Defined as trauma victims who fulfil all 4 clinical pre-conditions below 1) Glasgow Coma Scale (GCS) score 15 and appropriate 2) Not impaired by intoxicants, alcohol or sedation/opioid analgesics 3) No midline spinal tenderness, no deformity or steps and no neurological deficit referable to a spinal injury (e.g. abnormal tone, power or reflexes) 4) No significant distracting injury e.g. extremity fracture GROUP 2 PATIENTS Defined as trauma victims who do NOT meet 4 clinical pre-conditions and are not under care of ICU GROUP 3 PATIENTS Defined as trauma victims who do NOT meet 4 clinical pre-conditions above and are under the care of ICU and/or are intubated e.g. traumatic brain injury Trauma victim arrives with full spinal immobilisation applied (cervical collar, sandbags, tape and spinal board). Senior staff assess 4 clinical pre-conditions Group 1 Satisfy all 4 clinical preconditions. Spine may be regarded as stable and uninjured. Observe during mobilisation* Group 2 Do not meet all 4 clinical preconditions and are not under the care of ICU Maintain immobilisation as practical and perform 1)Lateral, AP and odontoid cervical plain radiographs 2) Consider thoracolumbar AP + lateral plain radiographs if appropriate mechanism Await improved GCS if necessary and apply 4 clinical pre-conditions again. If these satisfied and imaging is normal the spine may be regarded as stable and uninjured. Observe during mobilisation * Group 3 Do not meet all 4 clinical preconditions and are under the care of ICU or intubated. See algorithm overleaf * Weakness, paraesthesia or pain may indicate a missed injury Neurological deficit referable to the spine requires urgent consideration of MRI. Management of a detected injury must involve a senior neuro or orthopaedic surgeon

6 &&&& GROUP 3 PATIENT ALGORITHM! #"$ "# %'&)( * ( (",+ %$ -.+/ 0 %0 1$" /% " 5555 / 6 78 ( 1. / 9:("% " ;=<,>@?BADC E:FG*H/IG JKF LNMPO G/F!QR.O L1S T O J S.U O L1U'V1FH/IG6FXW Y[Z\IG M]1F.SM G/F^S._J^O QNQO I L 5555 à"bdc e h inm/fgpl1stjqo U L1QdIH QR.O L1S TNO Llkm.G n opi r s1tvunwx y ztjy.rpx { t{ v{ zt y*s~}n x z *u { t u y*zƒnx. vx z *} { }t jsˆ z{ t zšjtnu u z1 *znu y/œun{ z }w /{ tv ~ jzwjy6{ swvu Ž sƒn{ x { uvzvy/{ stn obi g P Ñ *š1 obi ÙÚ. % 1(Û".cq( 1 Ü Ý. 6Þß fqf.q fqf.q Re-evaluate. Low threshold to reinstate immobilisation & ATLS Guidelines fgf.q gœp ž Ÿ ž ž ž ž Xä ª0䫾 À µ ³ ¹ ²j³ µ ¹ ³ µ ³* Á ¹ ²j³ ¼Â¹»jµ ³* Á ²»j¼¼1à µ ³ ¹ Ä Á µ ³ ¹ NÅ ¼ ¹ à ½ µ» ²j³ Á» ¼ ²v ¹ ¹ Å ¼ ¹ à ½ µn» ² ³ Ä ² ¹ ³ ¼ * N ³/ µ¹ ² ³ ¹ ² ½ ¹ µ1¹ ¼ ²qÆ ¹ ³/ÇÈ v ² ¹ ¼ ² ¼ ¼ ¼ ³/Ç ¼Ãµ ¹» N N ¼ ² : v j ± ²j³ [µ ² µ ²j³ ³* ¹ ² º»j¼ ²j N ½ ³ µ ²j³ BOX A 1) Lateral, AP & odontoid cervical plain radiographs 2) Thoracolumbar AP + Lateral plain radiographs 3) High resolution cervical CT of the craniocervicial junction (to C2/C3) if inadequate. OR Helical/multi-slice CT of entire spine (hi-res for occiput to T2) if available, replacing all but initial lateral cervical spine XRay. BOX B ATLS Guidelines * Appropriate fitting Aspen or equivalent semi rigid collar and use of sandbags and tape where possible * Nurse on firm, flat mattress. (ATLS recommends patient is removed from rigid spinal boards following the primary survey) * All moves or transfers performed as log-roll with appropriate staff for size of patient É Ê Ê Ë Ì# Í Î Ê Ê Ê Ê Î/ ^ÍÏ.Ð/ ÊÊÊÊ Í. Ë Ë Ë Ë Ñ Ð*Ò^Ì^ Í ÍÍÍÍ ÊÕ XÖ.Ð/ N Ø Ða ÌÌÌÌ Ê Ë ËËËË - 6 -

7 Explanatory Notes: This protocol is intended to act as the preliminary screening process and management of spinal injuries amongst trauma victims admitted to hospitals in Northern Ireland. The mechanism of injury may be classified as: 1) High energy e.g. motor vehicle accident or a fall greater than the individual s height. 2) Low Energy in association with signs or symptoms of spinal injury eg apparently minor fall or a domestic accident. Up to 15% of spinal injuries may follow such a mechanism. Immobilisation of non-cleared trauma patients Within this guideline, consultant clinicians (e.g. intensive care) will take the decision to ceased spinal immobilisation, on a perceived risk/benefit basis. Until that point patients must be managed in line with ATLS guidelines: 1) In an appropriately fitting ASPEN or equivalent semi-rigid collar and use of sandbags and tape where possible. 2) On a firm, flat mattress. The use of spinal boards is under institutional review and ATLS guidelines recommend patients be removed from rigid spinal boards following the primary survey (i.e. within the emergency department). 3) All moves or transfers performed as logrolls with appropriate staff for the patient size. It is emphasised that the intention of these interventions is to avoid displacing unstable spinal injuries. Amongst agitated, intoxicated or uncooperative patients judgement must be employed as forcible restraint and attempted application of supine immobilisation may promote displacement and active movement of the patient s spine. Once the spine is cleared the patient can be moved cautiously and under supervision. Any subsequent evidence of weakness, spine or neck pain or paraesthesia must be considered as a potential missed injury and be evaluated further, with a low threshold to reinstitute immobilisation Complications of Immobilisation Among all patients the restoration of mobility is to be seen as a management priority. Cutaneous ulceration, pneumonia, sepsis and venous thromboembolism are among the more serious complications. The screening of group 3 patients is to be completed as rapidly as possible (target to be less than 48 hrs) since the incidence of cutaneous ulceration increases rapidly beyond this time. These can be life-threatening complications, which must be balanced against the very small risks of missing a spinal injury using this protocol

8 Plain radiographs A lateral cervical radiograph, especially in the emergency setting, may miss 15% of cervical injuries and a 3 view cervical series 5-10%: in unconscious patients, plain radiographs alone lack sensitivity to clear the cervical spine. If the middle of C7 cannot be seen on the lateral plain radiograph, under 8% of cases will have the cervicothoracic junction revealed by arm traction: consider using swimmer s or oblique plain film views or CT. Repeated attempts to obtain further (inadequate) lateral radiographs have risks, waste time and are to be avoided. Thoracolumbar spine Thoracolumbar spinal injury should be strongly suspected if any of the following are present: 1) High energy or appropriate impact, unconscious or intoxicated, or distracting injuries 2) Spinal tenderness or deformity, or appropriate neurological deficit Group 3 patients should have routine screening thoracolumbar plain radiographs, and a low threshold should be employed to screen group 2 patients. Unlike cervical trauma, isolated ligamentous injury of the thoracolumbar spine is extremely rare and plain radiographs are considered sufficient if technically adequate. Abdominal CT (if performed to assess the abdomen) may provide useful information with regard to bony injury of the thoracolumbar spine. Combined cervical plain radiographs and CT Among group 2 or 3 patients most evidence suggests plain films and directed CT (ie routine craniocervical scanning and further scanning of non-visualised or suspicious plain radiographic areas) performed in a complementary fashion have a high sensitivity for most unstable injuries; missing much less than 1% (including ligamentous injuries). Alternatively, entire high-resolution helical/multislice CT of cervical spine (occiput to T2) can replace plain cervical films in group 3 patients. There may be merit and little delay in a plain lateral film in the A&E department to identify an obvious injury prior to CT. Because of the complications of transferring the critically ill and the implications for subsequent care it is hoped that all but the most unstable patients can have their entire spinal evaluation performed before theatre or ICU admission: management of genuinely life threatening injuries must always take precedence over imaging which can be performed at a later date

9 MRI and Dynamic Fluoroscopy Routine use of MRI or dynamic fluoroscopy does not reliably improve performance and is not practical at present. Managing Detected Injuries Once an abnormality is detected on screening, especially following entire spinal imaging among group 3 patients, it is essential that this injury and its significance is assessed by a senior neuro or orthopaedic surgeon; typically in conjunction with a senior radiologist. The determination of stability or otherwise of a detected spinal injury, however apparently trivial, requires specialist advice