Elsevier

Injury

Volume 40, Issue 8, August 2009, Pages 880-883
Injury

Increased risk of death with cervical spine immobilisation in penetrating cervical trauma

https://doi.org/10.1016/j.injury.2009.01.011Get rights and content

Abstract

The purpose of this study was to determine if cervical spine immobilisation was related to patient mortality in penetrating cervical trauma. One hundred and ninety-nine patient charts from the Louisiana State University Health Sciences Center New Orleans (Charity Hospital, New Orleans) were examined. Charts were identified by searching the Charity Hospital Trauma Registry from 01/01/1994 to 04/17/2003 for all cases of penetrating cervical trauma. Thirty-five patient deaths were identified. Cervical spine immobilisation was associated with an increased risk of death (p < 0.02, odds ratio 2.77, 95% CI 1.18–6.49).

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.

References (20)

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