Clearing the cervical spine after polytrauma: implementing unified management for unconscious victims in the intensive care unit

Abstract

SummaryDetermining the best method for excluding cervical spine injury while a polytrauma victim is unconscious remains a controversial topic despite a number of published guidelines. A structured questionnaire demonstrated major differences between intensivists, neurosurgeons, orthopaedic surgeons and spinal surgeons with regard to the imaging modalities requested, the perception of their performance, the relative risks of missed injuries and the complications of immobilisation. Unconscious victims of polytrauma often come under the care of several subspecialties, with the direct consequence that management can be contradictory and lack standardisation. Advanced Trauma Life Support and Eastern Association for the Surgery of Trauma guidelines can reinforce and even contribute to non-standardised care. Having performed this clinician survey, we have now developed a multidisciplinary management protocol appropriate for Northern Ireland.

Spinal immobilisation for unconscious patients with multiple injuries

“…The requirement for skin grafting has been reported by 18.8% of specialists,14 and our unit has experienced septic shock and infected cervical prostheses after operative fixation have been reported in our unit. “Bed sores” require prolonged time to heal—each ulcer costing $30 000 (£17 000; €25 000) (fig 1).…”

“…Our survey of Northern Ireland's intensivists and trauma surgeons showed diverse practices. Worryingly, 12.5% of clinicians believed that plain radiography was adequate to exclude cervical injury, and the advanced trauma life support concept of a “generic expert” to provide standardised evaluation and “clearance” of cervical spine injury is a myth 14. Other workers have shown that 48% of UK intensive care units23 and 12-16% of American specialists24 were prepared to clear an unconscious patient's cervical spine by using a solitary lateral plain radiograph.…”

Advanced Trauma Life Support (ATLS) and facial trauma: can one size fit all?

“…Unfortunately there has been a lack of consensus on the optimal way to do this within the UK 48,70,99 and internationally 46 . Ideally, the neck should be cleared prior to the repair of any facial injuries, although this may not be possible 70,99 . Rigid spinal boards were originally developed as extrication aids for pre-hospital care.…”

Pride and prejudice

“…From critical care outreach [14] to trauma [15], from transplantation policy [16] to equipment design [17], from health service efficiency [18] to how best to train our future doctors [19], from epidemiology [20] to cost-effectiveness of novel therapies [21], and from ethical issues [22] to infection control [23], there are precious few areas within hospital medicine or the wider therapeutic community where anaesthetists do not play an active part in refining and improving the patient experience. I believe that there is a strong and cogent argument to be made that, at its best, anaesthesia more than any other specialty can represent the platonic ideal of the truly holistic doctor epitomised by John Snow, the earliest specialist in our art and voted as 'greatest doctor ever' by the readers of Hospital Doctor in 2003.…”