In message <[log in to unmask]>, [log in to unmask]
writes
>is there any evidence for the 
>statement
>>made below ?
>>
>>>Most of the patients we see who still have ?C-Spine after initial
>>>(hopefully immediate) de-boarding can be left in a hard collar (not
>>>taped) and told to keep still. Any conscious, coherent person with a
>>>broken neck will NOT want to move anyway.
No evidence, just years of experience seeing endless patients whith only
criteria to XRay being "pain on mvt" (i.e. it hurts a little bit when
they look behind them). NONE of them have had a positive XRay. (I would
definitely have been told by the boss if I had missed any). Our
population may be very different to others: we have a lot of "worried
but well" horse-riders and low-speed RTAs with slightly sore necks. They
have minimal criteria to XRay them, so I XRay them. I'll let the list
know when I see one of these come back with a positive XRay (none so far
in 7 years and countless hundreds of XRays).

The only conscious person I've seen with a positive C-spine XRay was
clinically highly suspicious before the XRay (tingling arms, pain+++,
wouldn't let go of his head etc.). We fully immobilized him before XRay.
Patients who are drunk / sedated / head-injured / have distracting
injuries etc: always have c-spine injury until XR/CT/MRI says otherwise.

As for not taping: remember Mike's guy trying to climb the walls? If the
patient (with low suspicion of C-spine) does decide to move, taped /
bagged fixation is a disaster unless you institute full body
immobilization too (may require potentially dangerous sedation / GA /
IPPV in a number of patients). The irrational, agitated drunk with a
possivble (not probable) neck injury may better tolerate a collar alone
than collar / tape / body strapping. This may be a reasonable compromise
if the risks of GA / paralysis / IPPV outweigh the very low risk of c-
spine injury.

I can hear the purists' flame-throwers warming up now: "you can't
compromise if there's even a small chance of a C-spine injury". I've
been told a tragic story involving an A&E SHO who wishes they HADN'T
followed guidelines slavishly in dealing with neck injuries as it
resulted in a fatal worsening of a neck injury. Rare maybe, but real.

I assume a collar is better than nothing, although I've not seen any
evidence. The practicalities are that if the agitated patient has been
flailing around in a pub  /police van / mates car before arriving, then
any C-spine injury is likely to pretty stable anyway. Fighting the
patient to accept constraints may potentially worsen the situation.

(must check my MPS subs are paid up!)


>I have seen C grades remove a collar and just
>
>>leave bags and tape, others just use a collar and others still use both.

Look at:
Pre-hospital immediate care 3:17 (1999) (houghton et al)
In brief: Tests on healthy volunteers shows that collar adds nothing to
tape / block, but even that it not particularly good immobilization.

If the head is FIXED (not just collar), then the body MUST be too.


Dr G Ray
Staff Grade
A&E
Sussex
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