Advanced Trauma Life Support ATLS Student Course Manual 2018
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CHAPTER 7 n Spine and Spinal Cord <strong>Trauma</strong><br />
box 7-1 guidelines for screening patients with suspected spine injury<br />
Because trauma patients can have unrecognized<br />
spinal injuries, be sure to restrict spinal motion until<br />
they can undergo appropriate clinical examination<br />
and imaging.<br />
Suspected Cervical Spine Injury<br />
1. The presence of paraplegia or quadriplegia/tetraplegia is<br />
presumptive evidence of spinal instability.<br />
2. Use validated clinical decision tools such as the Canadian<br />
C-Spine Rule and NEXUS to help determine the need for<br />
radiographic evaluation and to clinically clear the c-spine.<br />
Patients who are awake, alert, sober, and neurologically<br />
normal, with no neck pain, midline tenderness, or a<br />
distracting injury, are extremely unlikely to have an<br />
acute c-spine fracture or instability. With the patient in<br />
a supine position, remove the c-collar and palpate the<br />
spine. If there is no significant tenderness, ask the patient<br />
to voluntarily move his or her neck from side to side and<br />
flex and extend his or her neck. Never force the patient’s<br />
neck. If there is no pain, c-spine films are not necessary,<br />
and the c-collar can be safely removed.<br />
3. Patients who do have neck pain or midline tenderness<br />
require radiographic imaging. The burden of proof<br />
is on the clinician to exclude a spinal injury. When<br />
technology is available, all such patients should undergo<br />
MDCT from the occiput to T1 with sagittal and coronal<br />
reconstructions. When technology is not available,<br />
patients should undergo lateral, AP, and open-mouth<br />
odontoid x-ray examinations of the c-spine. Suspicious<br />
or inadequately visualized areas on the plain films may<br />
require MDCT. C-spine films should be assessed for:<br />
• bony deformity/fracture of the vertebral body<br />
or processes<br />
• loss of alignment of the posterior aspect of the<br />
vertebral bodies (anterior extent of the vertebral canal)<br />
• increased distance between the spinous processes at<br />
one level<br />
• narrowing of the vertebral canal<br />
• increased prevertebral soft-tissue space<br />
If these films are normal, the c-collar may be removed to<br />
obtain flexion and extension views. A qualified clinician<br />
may obtain lateral cervical spine films with the patient<br />
voluntarily flexing and extending his or her neck. If the<br />
films show no subluxation, the patient’s c-spine can be<br />
cleared and thec-collar removed. However, if any of<br />
these films are suspicious or unclear, replace the collar<br />
and consult with a spine specialist.<br />
4. Patients who have an altered level of consciousness or<br />
are unable to describe their symptoms require imaging.<br />
Ideally, obtain MDCT from the occiput to T1 with sagittal<br />
and coronal reconstructions. When this technology is<br />
not available, lateral, AP, and open-mouth odontoid<br />
films with CT supplementation through suspicious or<br />
poorly visualized areas are sufficient.<br />
In children, CT supplementation is optional. If the<br />
entire c-spine can be visualized and is found to be<br />
normal, the collar can be removed after appropriate<br />
evaluation by a doctor skilled in evaluating and<br />
managing patients with spine injuries. Clearance of the<br />
c-spine is particularly important if pulmonary or other<br />
management strategies are compromised by the inability<br />
to mobilize the patient.<br />
5. When in doubt, leave the collar on.<br />
Suspected ThoracoLUMbar Spine<br />
Injury<br />
1. The presence of paraplegia or a level of sensory loss<br />
on the chest or abdomen is presumptive evidence of<br />
spinal instability.<br />
2. Patients who are neurologically normal, awake, alert,<br />
and sober, with no significant traumatic mechanism<br />
and no midline thoracolumbar back pain or tenderness,<br />
are unlikely to have an unstable injury. Thoracolumbar<br />
radiographs may not be necessary.<br />
3. Patients who have spine pain or tenderness on<br />
palpation, neurological deficits, an altered level of<br />
consciousness, or significant mechanism of injury<br />
should undergo screening with MDCT. If MDCT is<br />
unavailable, obtain AP and lateral radiographs of the<br />
entire thoracic and lumbar spine. All images must be of<br />
good quality and interpreted as normal by a qualified<br />
doctor before discontinuing spine precautions.<br />
4. For all patients in whom a spine injury is detected or<br />
suspected, consult with doctors who are skilled in<br />
evaluating and managing patients with spine injuries.<br />
5. Quickly evaluate patients with or without neurological<br />
deficits (e.g., quadriplegia/tetraplegia or paraplegia) and<br />
remove them from the backboard as soon as possible. A<br />
patient who is allowed to lie on a hard board for more<br />
than 2 hours is at high risk for pressure ulcers.<br />
6. <strong>Trauma</strong> patients who require emergency surgery before<br />
a complete workup of the spine can be accomplished<br />
should be transported carefully, assuming that an<br />
unstable spine injury is present. Leave the c-collar in<br />
place and logroll the patient to and from the operating<br />
table. Do not leave the patient on a rigid backboard<br />
during surgery. The surgical team should take particular<br />
care to protect the neck as much as possible during the<br />
operation. The anesthesiologist should be informed of<br />
the status of the workup.<br />
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