There is a lot of angst out there among trauma professionals when it comes to clearing the cervical spine and possible distracting injuries. I’ve written about this before, and the most important technique I use is to try to see if the patient is aware of pain in areas distant from the suspected distraction.
A recent prospective study looked at injury patterns and c-spine clearance in over 9,000 trauma patients at a single Level I trauma center. Of those, 101 were evaluable (not intoxicated, no head injury) and actually had a cervical fracture. 96% of them were symptomatic, despite the majority having what would normally be considered a distracting injury (87%). Of the 4 who did not have pain or tenderness on examination of the neck, every one of them had a distraction.
There was a pattern as to which “distracting” injuries were really a distraction. All four of the asymptomatic patients had bruising or tenderness to the upper anterior chest, which diverted their attention away from their neck. Other injuries caused pain in some of these patients, but it was outweighed by the chest wall pain.
Bottom line: Distracting injury is currently defined too liberally, which results in lots of patients getting lots of unneeded cervical spine imaging. Although this study is small, it adds one more piece of information to the c-spine clearance puzzle. I personally will add this to my current practice and clear the cervical spine if:
The patient is aware of multiple sources of pain
Subjective pain scale overall is less than 6 (otherwise provide better pain control!)
There is no pain/tenderness/injury to the upper chest
Reference: The presence of nonthoracic distracting injuries does not affect the initial clinical examination of the cervical spine in evaluable blunt trauma patients: a prospective observational study. J Trauma 71(3):528-532, 2011.
This patient was running from an assailant at top speed and fell, tumbling for several feet. Medics found him in this position and pondered how to secure him for transport. eventually they just used straps and belts to hold him on a backboard.
The injury is an interesting one. He has a femur fracture, but there is a twist (literally). If he was a contortionist and had found a way to bend his knee toward his head, his toes would point to his face. If you look at the thigh, twisted muscle bellies can be seen.
The diagnosis is a mid-shaft femur fracture with a 180 degree rotation of the distal portion.
I’ve written several times on the importance of getting patients off the backboard promptly in the ED. Many hospitals use slide boards to facilitate patient movement on and off the ED cart when undergoing imaging studies. How should we manage the use of this device?
There is no difference between a backboard and a slide board to the patient. It’s hard and uncomfortable to lie on for any period of time, and can cause soft tissue injury. To trauma professionals in the ED it is thinner, less bulky, easier to manipulate, and does not interfere with xrays as much. We tend to pay less attention to it than a backboard. Although it does not immobilize the spine as well as a backboard does, the difference is not clinically significant (in a cooperative patient). Remember, if your patient actually has a spine fracture, they will be placed on logroll precautions on a soft mattress only somewhere in your hospital! No stiff boards of any kind!
Slide board management tips:
Slide boards are for blunt trauma only! Patients with penetrating injury may need an upright chest xray in the ED and the board won’t flex enough.
Insert the slide board in any patient who will be getting several diagnostic studies. For trauma activation patients, this can occur as you roll them off the backboard.
As soon as diagnostic studies are done, remove the slide board
If there are unforeseen delays, remove the slide board and reinsert when ready to move
Remember that the soft tissue timer is counting down as soon as the patient is placed on a backboard or slide board
Plan an efficient road trip through diagnostic studies for your patient. This allows you to minimize time on the board.
Repeated logrolls onto and off of the slide board are discouraged. Every roll is an opportunity for mishap.
I find that many trauma professionals are nervous about closing stab wounds. They seem to worry a lot about infections and lean toward leaving the wound open to heal by secondary intention. But is this warranted?
The answer is: probably not. Most knives used for assaults are clean, but not quite sterile. Yes, there are a few bacteria on the blade, but not very many. So if the usual wound management guidelines are followed, the patients generally do quite well.
The guidelines are:
No gross contamination. If the knife was used to cut raw chicken or to stir up manure, that’s a problem. Leave it open.
No devitalized tissue. Complex lacerations with dusky skin bridges may get infected. Debride or leave open.
Don’t let the wound get fully colonized with skin bacteria. There is no good literature on this, but more than 12 hours for most of the body and 24 hours for the face is a reasonable guideline.
If any of these guidelines have been violated, it’s probably best to leave the wound open. Otherwise the default should be to try to close it as soon and as cleanly as possible. This means irrigating with saline to decrease any bacterial counts. Either sutures or staples are acceptable.
The most important part of this process is patient education. They must be informed about what signs of a wound infection to look for so they can return earlier rather than later to have you deal with it.