Increased risk of death with cervical spine immobilisation in penetrating cervical trauma
Introduction
Vascular and airway injuries complicating penetrating cervical trauma require emergency intervention. Vascular injury complicates over 25% of penetrating cervical trauma with an associated mortality of up to 50%.5, 12, 14, 17, 20 Exsanguination was reported as the cause of 50% of penetrating cervical trauma deaths20 and is the leading cause of death in patients with penetrating cervical trauma.14, 16 Airway injury occurs in approximately 10–18% of patients with penetrating cervical trauma.14, 16 The rapid mortality associated with vascular and respiratory tract injuries has lead many authors to stress the importance immediately treating these life-threatening injuries before addressing concerns about cervical spine instability.8, 9, 10, 12, 15, 19 Increased mortality with delayed transport to definitive surgical care in cases of penetrating cervical trauma has been reported.7 Transport delays from cervical spine protection measures have been variably reported from a mean of 8 min to >30 min.1, 6 Clevenger et al. demonstrated that patients with penetrating trauma experienced a fourfold increase in on scene times with traditional field preparation as compared to a “scoop and run” policy in which rapid patient transport was emphasised.6 Approximately 75% of the total transport time was accounted for by time on scene.6 Mean total field times were reduced 43% from 46 min to 20 min6 by initiation of the “scoop and run” policy. This decreased field time translated to increased patient survival from resuscitative thoracotomy. Seamon et al. reported increased mortality associated with cervical spine immobilisation (c-spine immobilisation) in penetrating trauma patients requiring resuscitative thoracotomy.19
Cervical collars can impede medical care.13, 15, 18 Endotracheal intubation was associated with increased attempts and higher failure rates in c-spine immobilised patients.11, 13 Compromised survival resulting from reluctance to remove a cervical collar to treat life-threatening injuries has been reported.2 Barkana et al. emphasised that physical manifestations indicating the severity of injury can be masked by cervical collars.3 Indicators of severe penetrating cervical injury include active external bleeding, the presence of a cervical bruit or thrill, dysphonia, dysphagia, subcutaneous emphysema, oropharyngeal haemorrhage, a sucking neck wound, neurological deficits, and a large or expanding or pulsatile haematoma.3, 4 Five of these nine clinical indicators of significant injury with penetrating cervical trauma can be hidden by the presence of a cervical collar; active external bleeding, a cervical bruit or thrill, subcutaneous emphysema, a sucking neck wound, and a large or expanding or pulsatile haematoma. Britt and Trunkey both recommended direct pressure to treat cervical haemorrhage, which can clearly be encumbered by a cervical collar.4, 14 Barkana also noted that tracheal deviation can be obscured by a cervical collar.3
No studies have examined the effect of c-spine immobilisation and patient survival in penetrating cervical trauma. C-spine immobilisation was hypothesised to negatively impact outcome in penetrating cervical trauma given (1) the frequency and severity of associated vascular and respiratory tract injuries, (2) the time requirements for field c-spine immobilisation, and (3) the possibility of impeded medical care. The purpose of this study was to determine if patient mortality differed between those patients who were or were not c-spine immobilised.
Section snippets
Materials and methods
Retrospective chart analysis performed from the trauma registry of an American College of Surgeons, level I trauma centre. The Louisiana State University Health Sciences Center, New Orleans (Charity Hospital, New Orleans), Trauma Registry was searched from 01/01/1994 to 04/17/2003 for all cases of penetrating cervical trauma. Charts were excluded for lack of penetrating cervical trauma, incompleteness, death, patient elopements prior to evaluation and patient discharges “against medical
Results
Eight hundred and forty-seven charts were identified. The charts were arranged alphabetically by last name and then sequentially numbered. Charts were linearly and sequentially examined. The total number of patient charts reviewed was 199 before Hurricane Katrina destroyed the remaining charts. Charts were examined from A through FAZ before Hurricane Katrina struck. Patients were evenly distributed by year over the study interim. The number of patients per year ranged from 18 to 30 except for
Discussion
C-spine immobilisation in this study was associated with an increased risk of death (p = 0.016, odds ratio 2.77, 95% CI 1.18–6.49). Most of the patients who died in the Emergency Department presented with paroxysmal electrical activity (PEA) cardiac arrest indicating that exsanguination or hypoxia was the most probable cause of death. Multiply injured patients were separated from those patients with isolated cervical injury to examine the mortality risk of c-spine immobilisation with penetrating
Conflict of interest statement
The authors report that they have no conflicts of interest.
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Cited by (37)
Wilderness Medical Society Clinical Practice Guidelines for Spinal Cord Protection
2019, Wilderness and Environmental MedicineCitation Excerpt :Haut et al evaluated 45,284 patients with penetrating trauma and showed overall mortality to be twice as high in spine-immobilized patients (15 vs 7%; P<0.001).21 A common observation in these studies is that cervical spine immobilization could mask important clinical signs, such as tracheal deviation, expanding hematoma, and diminished or absent carotid pulse, and may impair successful endotracheal intubation.19,28,103 The Committee on Tactical Combat Casualty Care recommended a balanced approach to cervical spine precautions when a significant mechanism of injury exists.104,105
Improvised vs Standard Cervical Collar to Restrict Spine Movement in the Backcountry Environment
2019, Wilderness and Environmental MedicineMajor Trauma Outside a Trauma Center: Prehospital, Emergency Department, and Retrieval Considerations
2018, Emergency Medicine Clinics of North AmericaCervical collars and immobilisation: A South African best practice recommendation
2017, African Journal of Emergency MedicineShould suspected cervical spinal cord injury be immobilised?: A systematic review
2015, InjuryCitation Excerpt :Five studies lacked adjustment for key confounders such as ISS, age, sex, and mechanism of injury [33,35,36,39,40], and two studies lacked reporting on patient demographics, limiting the ability to ascertain internal and external validity [35,40]. Vanderlan et al. have based their results on a subset of the patient cohort (n = 153) and failed to explain 35 patient charts which were excluded from review [33]. Another two studies lacked reporting on loss to follow up [37,39].
Wilderness medical society practice guidelines for spine immobilization in the austere environment: 2014 update
2014, Wilderness and Environmental MedicineCitation Excerpt :In addition to the risk of further injury to the patient as a consequence of increasing the danger of rescue, spinal immobilization is associated with documented risks and rather extreme discomfort. Although the expert panel was unable to identify a single well-documented case in the literature of prehospital neurologic deterioration as a direct consequence of improper or inadequate immobilization, many cases have documented severe morbidity, and even mortality, secondary to immobilization itself.2,15–26 For the purpose of developing proper guidelines for spinal immobilization in a dangerous environment, it is important to recognize and attempt to differentiate 5 types of spinal injury scenarios: 1) an uninjured spine; 2) a stable spine injury without existing or potential neurologic compromise; 3) an unstable, or potentially unstable, spine injury without apparent neurologic compromise; 4) an unstable spine injury with neurologic compromise; and 5) a severely injured patient with unknown spinal injury status.