There is a good discussion of the issues at:
http://www.trauma.org/spine/index.html
A good article on clearing the C spine clinically is:
J Trauma 1996;40:383-389
There are good guidelines at:
http://www.east.org/tpg/chap3body.html
>
> Ok I may be being thick here and may have missed a paper on this but
> how about this scenario.... An adult patient with a GCS of 15 is
> brought from a RTA. He has midline cervical spine tenderness but no
> apparent abnormality of his CNS or Peripheral NS. Q1 Do you put him in
> a hard collar or tape him down or both ?. I have worked with senior
> colleagues in various establishments where a mixture of the above
> occurs.(Despite ATLS training!)
>
In an awake patient why do we use tape? Most patients will lie still, so the
rationale is probably that the tape is an aide memoir to staff (and patient), and
prevents the head moving when some idiot bangs into the trolley. Many people
seem to think that the tape is a form of restraint - this is muddled thinking. If we
are trying to restrain the patient using head tape then we should probably be
restraining the rest of the body too! (This is the same situation as in an
ambulance where the head can be securely taped, but the unrestrained body
slides sideways on the nice slippery spinal board as the ambulance goes
around a corner).
It is not acceptable to use a 'collar only' instruction as a sort of halfway house
(Patient should not be sitting in the waiting room in a hard collar). In the same
way as it is not possible to be 'a little bit pregnant' the spine is either treated as
'cleared' or 'potentially unstable'.
I would have this patient lying down with collar, sandbags and head tape.
> Q2 If he had some localising neuro signs would that change your
> thinking?
>
About restraint - not really.
> Q3 If he was GCS 14-13 would that change your view?
>
Yes. I would be worried that the patient would move their body and so a secured
head would be potentially harmful. Manual in line immobilisation would allow
head and body to move together. If the patient is unco-operative they obviously
require urgent intubation and ventilation.
> Q4 Is there any evidence for any of this ?
>
See EAST guidelines for a good summary of the evidence (which is difficult to
interpret, mainly because many studies do not define the entry criteria).
> Q5 Or am I just being thick ? (and the answer is probably yes)
>
No. It is a worldwide problem - which has probably been given some undue
prominance by the ATLS dogma. (I wish people would worry about pulse
pressure and respiratory rate as much as they worry about the c spine).
Tim.
Timothy J Coats MD FRCS FFAEM
Senior Lecturer in Accident and Emergency / Pre-Hospital Care
Royal London Hospital, UK.
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