Evaluation and Initial Management of Cervical Injuries

Abstract

The goals for evaluation and initial management of cervical injuries are prompt recognition of the problem and prevention of secondary neurological damage. Missed diagnoses are common because of the difficulty in identification of cervical spine trauma, particularly in polytrauma patients with altered level of consciousness. Close adherence to a well-reasoned spine clearance protocol may decrease the incidence of missed injury in polytrauma patients. It is estimated that 2 to 3% of all trauma patients, and 10% of patients with serious head injuries, sustaincervicalspineinjuries, 1 andofthose,between3and25% suffer extension of those injuries from delay in diagnosis or unwarrantedmanipulationintheemergencydepartment. 2 In this article, the protocols for evaluation and initial managementofcervicalspineinjuries“Onthescene,”“Playingfield,” and “In the trauma bay” have been reviewed. On the Scene Management of any obvious or potential cervical spine injury should be a part of the overall patient stabilization and preparation at the scene of the injury, before transfer to the hospital. The circumstances of the accident or injury should be assessed quickly. The basic life support measures should be initiated according to the Advanced Trauma Life Support (ATLS) 3 protocol with A (airway protection), B (breathing andventilation),andC(maintaineffectivecirculation)inthat order. The spine (especially, but not exclusively, the cervical spine) should also be protected while the ABC measures are instituted. The patient’s neck should not be hyperextended, hyperflexed, or rotated, which is especially difficult to avoid while trying to maintain the airway. Ideally, preventing such neck movements can be facilitated with appropriate cervical immobilization devices (eg, hard collar and tape). If these are not immediately available, sandbags or rolled-up pieces of clothing can be used as temporary support until a paramedic crew arrives. Use of spinal boards offers a very effective and easy-to-use means of transferring trauma patients. Asking patients simple questions, such as their name and areas of pain, and providing plenty of reassurance will help calm them and will also help in the assessment of their neurological status. If appropriate responses are received, then simple commands to move arms and legs should provide an immediate overview of the gross neurological status. Presence of peripheral injuries (eg, fractures) may make movement extremely painful and may interfere with neurological assessment. A careful record of the neurological status in the initial stage is extremely important in further management of thepatient.Neurologicalexaminationbecomesdifficultifthe patient loses consciousness or needs to be sedated at a later stage. The baseline neurological status serves as a guide to any deterioration during the subsequent course of treatment and also helps to classify any spinal cord injury as complete versus incomplete, which has important implications in prioritizing surgical stabilization of the spine. Effective pain relief is important in the initial treatment of a trauma patient. Caution should be exercised when administering high doses of opiates or other sedatives, which may depress the level of consciousness. If the patient becomes drowsy or comatose or has significant facial injuries, intubation/ventilation should be considered for airway protection and safe transfer. Patients with a score lower than 8 on the Glasgow Coma Scale (GCS) should definitely be intubated before transfer. Pupillary asymmetry and reaction to light should be assessed because they can indicate significant intracranial pathology.