What is the recommended evaluation and treatment approach for a 1-day post-accident patient with neck muscle stiffness and vomiting after a rear-end collision, wearing a seat belt (SB), with no loss of consciousness (LOC) or airbag deployment?

Immediate Evaluation and Management of Post-Motor Vehicle Collision Patient with Neck Pain and Vomiting

This patient requires immediate emergency department evaluation with cervical spine CT imaging and assessment for intracranial injury, as vomiting following head/neck trauma is a red flag symptom that may indicate serious complications including concussion, increased intracranial pressure, or the oculocardiac reflex from muscle entrapment. 1

Critical Red Flags Requiring Immediate Action

Vomiting as a Warning Sign

• Vomiting that develops the morning after trauma is a concerning symptom that warrants emergency medical evaluation 1
• The American Heart Association identifies vomiting as a sign of severe head injury requiring EMS activation 1
• In the context of orbital or cervical trauma, vomiting combined with neck symptoms may indicate the oculocardiac reflex from entrapped muscle tissue, which can be life-threatening 1
• Vomiting is also a cardinal symptom of concussion and may indicate evolving intracranial pathology 1

Cervical Spine Injury Concerns

• Despite no recalled head impact, cervical spine injury must be assumed until definitively excluded in any patient with neck trauma and midline tenderness 2
• The whiplash mechanism from rear-end collisions can cause significant soft tissue injury even without direct head contact 3, 4
• Rigid cervical collar immobilization is mandatory until cervical spine injury is excluded 1, 2

Recommended Diagnostic Workup

Imaging Protocol

• CT of the cervical spine is the appropriate initial imaging modality with 94-100% sensitivity compared to 49-82% for plain films 1, 2
• Plain radiographs alone are insufficient for excluding cervical spine injury in symptomatic patients with tenderness and limited range of motion 2
• Head CT should be strongly considered given the vomiting, as this meets criteria for possible intracranial injury 1

Clinical Assessment

• Perform thorough neurological examination including pupillary response, visual fields, and cranial nerve testing 1
• Check vital signs carefully for bradycardia or heart block, which combined with vomiting may indicate oculocardiac reflex 1
• Document range of motion limitations, midline tenderness, and any focal neurological deficits 1, 2

Management Algorithm

Immediate Phase (Day 1-2)

1. Maintain cervical collar until imaging completed and injury excluded 1, 2
2. Transport to emergency department for evaluation - do not attempt clinical clearance in office setting 1, 2
3. Obtain CT cervical spine and consider head CT based on vomiting symptom 1, 2
4. If CT negative but symptoms persist, consider MRI for ligamentous injury evaluation 1, 2, 4

Clinical Clearance Criteria

The American College of Radiology states that clinical clearance requires ALL of the following to be absent 2:

• No midline tenderness or pain
• Full range of active movement without pain
• No neurological deficits
• Alert and oriented
• No intoxicants
• No distracting injuries

This patient does NOT meet clearance criteria due to neck stiffness and vomiting 2

Subacute Management (If Imaging Negative)

• Ice application for first 24 hours, then heat 3
• NSAIDs and muscle relaxants for symptom control 3
• Minimize cervical collar use after 48-72 hours once injury excluded, as prolonged immobilization increases morbidity 2, 3
• Early passive mobilization and range of motion exercises may accelerate recovery 3

Critical Pitfalls to Avoid

Common Errors

• Never assume cervical spine stability based on absence of neurological deficits alone 2
• Do not rely on patient's lack of recalled head impact to exclude serious injury - whiplash mechanism can cause significant trauma without direct contact 3, 4
• Vomiting should never be dismissed as simple motion sickness or anxiety - it requires evaluation for intracranial injury and concussion 1
• Plain films miss 18-51% of cervical spine fractures depending on location 2

Delayed Complications

• Rare but serious complications can occur weeks to months after whiplash injury, including vertebral artery dissection leading to stroke 5
• More than 30% of patients report persistent neck pain at 2 years, with risk factors including older age, interscapular pain, occipital headache, and reduced range of motion at presentation 3
• If pain persists beyond 2 weeks despite negative CT, MRI is indicated to evaluate for occult ligamentous injury 1, 2

Disposition Decision

This patient requires emergency department evaluation today and should not be managed in an outpatient setting given the combination of neck trauma mechanism, muscle stiffness with limited range of motion, and particularly the concerning symptom of vomiting that developed overnight. 1, 2