What is the management plan for a patient with spine trauma in the emergency room (ER)?

Management Plan for Spine Trauma Patients in the Emergency Room

Early spine immobilization is strongly recommended for any trauma patient with suspected spinal cord injury to limit neurological deterioration in the initial phase. 1

Initial Assessment and Stabilization

Immobilization

• For patients presenting with any of the following, immediate spine immobilization is indicated:

  • Spinal pain
  • Focal neurological deficit
  • Altered consciousness
  • Intoxication
  • Distracting injuries 1, 2

• Preferred immobilization technique:

  • Head-neck-chest stabilization with rigid neck brace
  • Vacuum mattress for transport (superior to hard backboard) 1, 3
  • Avoid log rolling maneuvers when possible as they create more motion in the unstable spine 4

Airway Management

• For patients requiring intubation:
  • Use manual in-line stabilization (MILS)
  • Remove anterior part of cervical collar during intubation
  • Employ rapid sequence induction with direct laryngoscopy
  • Use a gum elastic bougie to increase first-attempt success
  • Maintain cervical spine in axis without Sellick maneuver 1

Hemodynamic Management

• Maintain systolic blood pressure >110 mmHg before injury assessment to reduce mortality 1, 2
• For patients with confirmed spinal cord injury, maintain mean arterial pressure (MAP) up to 70 mmHg during the first week to limit risk of neurological deterioration 1

Clinical Evaluation for Cervical Spine Clearance

Patients can be categorized into four groups:

1. Alert and Asymptomatic Patients

   • Cervical spine can be safely cleared clinically if ALL criteria are met:
     • GCS 15 with normal alertness
     • No intoxication
     • No neck pain/tenderness
     • No distracting injuries 2

2. Temporarily Non-Assessable Patients

   • Continue immobilization until proper assessment possible

3. Symptomatic Patients

   • Require imaging and continued immobilization

4. Obtunded/Unconscious Patients

   • Require imaging and continued immobilization 2

Imaging

Initial Imaging

• For patients not meeting clinical clearance criteria:
  • High-resolution CT of entire cervical spine (1.5-2mm slices) with sagittal reconstructions is preferred due to higher sensitivity 2
  • Three-view cervical radiographs (lateral, anteroposterior, odontoid) may be used if CT unavailable, but miss approximately 15% of cervical injuries 2

Additional Imaging

• MRI is urgently indicated for patients with:
  • Neurological deficits referable to the spine
  • Suspected ligamentous injuries not detected on CT 2

Management Decisions

• Transfer to Level 1 trauma center if available, as this is associated with:

  • Earlier surgical procedures
  • Reduced ICU length of stay
  • Improved neurological outcomes 1

• Surgical consultation for:

  • Spinal cord compression
  • Vertebral instability
  • Progressive neurological deterioration 2

Complications to Monitor

• Pressure ulcers (up to 55% of immobilized patients)
• Increased intracranial pressure
• Respiratory complications
• Venous thromboembolism (7-100% in patients with tetraparesis) 2
• More than 50% of patients with acute traumatic spinal cord injury will experience at least one complication during hospitalization 5
• Most complications (>75%) occur within 2 weeks of injury 5

Common Pitfalls to Avoid

1. Prolonged immobilization on hard backboard

   • Remove spinal board within two hours of ED arrival
   • Transfer to padded rigid surface or vacuum mattress 6

2. Missing cervicothoracic junction injuries

   • Up to 60% of injuries may occur at this junction
   • Ensure adequate visualization in imaging 2

3. Overlooking isolated ligamentous injuries

   • Occur in 0.1-0.7% of blunt trauma patients
   • May not be detected on plain films or CT 2

4. Unnecessary immobilization of penetrating trauma patients

   • Strong recommendation against spinal stabilization for patients with isolated penetrating trauma 3

5. Inadequate blood pressure management

   • Hypotension (SBP <110 mmHg) is an independent factor for mortality 1