TRAUMATIC HEAD, NECK, AND SPINE INJURIES
From High Risk Emergency Medicine, sponsored by the Center for Emergency Medical Education
Kevin M. Klauer, DO, Clinical Assistant Professor, Department of Internal Medicine and Osteopathic Medicine,
Michigan State University College of Osteopathic Medicine, Director, Quality and Clinical Education, Emergency
Medicine Physicians, Ltd, and Director, Center for Emergency Medical Education, Canton, OH
| Risk management issues: failure to diagnose—most common issue; frequency of malpractice claims 2%; inadequate
patient assessment contributes to failure, particularly in patients with subtle brain injury; pay attention to signs and symptoms,
eg, altered mental status, progressive headache, vomiting, to avoid missing significant brain injury in patient with
minor head trauma (minor head injury refers only to mechanism of trauma and not to brain injury); failure to
recognize—computed tomography (CT) may show significant brain injury in patient who does not look sick; loss of
consciousness (LOC) not necessary for traumatic brain injury (TBI); results from delay in, or not obtaining, CT; inadequate
patient management—prevent hypoxemia and hypotension in patient with TBI; delay in obtaining neurosurgical
consultation—call for neurosurgical consultation before CT if clinical suspicion of significant brain injury high;
make sure to document in chart that consult requested; reluctance to observe or admit patient—observe in emergency
department (ED) or admit patient with head injury who has negative CT if suspicion high for TBI; transfer patients who
need definitive management not available at facility
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| Physical assessment: history-taking—motor vehicle accidents (MVA) most common mechanism of injury for TBI;
falls, assaults, and other mechanisms also can cause TBI; signs and symptoms of TBI—transient LOC; altered mental
status (amnesia for all or part of event equivalent to altered mental status); and pre- or post-trauma seizure (obtain CT either
way); vomiting (even if single episode; obtain CT); nausea not predictor for TBI; check for previous brain injuries,
especially in patients who have alcohol-abuse histories (patients who abuse alcohol can sustain serious TBI even with minor
head trauma); obtain CT in patient with coagulopathy (eg, patient on warfarin) and admit, even if CT normal and international
normalized ratio (INR) normal; vital signs—chart containing incomplete set of vital signs may signal
inadequate standard of care to jury in potential malpractice case; evaluate patient for presence of drugs and/or alcohol;
neurologic scores—list scores in chart (use modified Glasgow coma scale [GCS] for patients <2 yr of age); trauma
above clavicles—consider imaging studies to look for TBI; CT findings—normal; needs emergent neurosurgical evaluation;
significant TBI not requiring emergent neurosurgical evaluation; therapeutically inconsequential brain injury (ie,
findings on CT do not alter management) considered “missable” in Canada, but in United States, must be identified because
of climate of risk; limitations and value of ED evaluation—GCS creates reproducible score that allows physician
to follow trend; perfect score not equal to negative CT; GCS not designed to determine whether patient needs CT;
absolute indications for CT—GCS score <15 (moderate-to-severe head injury); depressed skull fracture, unequal pupils,
clinical signs of basilar skull fracture, nontender ecchymosis under eyes or at mastoid processes, neural deficits,
posttraumatic seizure, penetrating head trauma, and graze wound; use clinical decision-making rule to determine whether
patient with GCS score of 13 to 15 needs CT; study data—Canadian study looked at 3100 patients with minor head injury;
neurosurgical intervention needed in 1%; increased rate of neurosurgical intervention with decreasing GCS score,
eg, with score of 13, frequency of significant brain injury 79%; risk factors for patients with minor head injury—TBI,
intracranial injury and hematoma, significant facial fractures or cranial soft tissue injuries, and significant coagulopathy
(patients on warfarin must have CT); American College of Emergency Physicians (ACEP) recommends CT in patient
>60 yr of age who sustains even minor head trauma; CT recommended in patient <2 yr of age, especially with signs of
external trauma; patient with persistent complaints after head injury should undergo CT; obtain CT if patient intoxicated,
exhibits inappropriate level of consciousness, or if head injury secondary to fall from seizure
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| Pediatric head injuries: study data—no significant injury in 93% of patients; TBI occurred in 7% of patients, but
only 2% to 5% of patients required intervention; study looking at blunt trauma after head trauma—2043 children
10 days to 18 yr of age who had low-risk criteria; 62.2% underwent CT, and ≈8% had TBI; sensitivity for TBI 99%;
number of CTs performed reduced by 25%; clinical decision rule for obtaining CT includes abnormal mental status,
hematoma in children <2 yr of age, presence or suspicion of basilar skull fracture, headache, or vomiting
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 | Physical assessment: use modified GCS in pediatric patients; clinical assessment correlates poorly with TBI findings in
children; children <6 mo of age—high percentage of asymptomatic and occult brain injuries; tolerate space-occupying
lesions well because of unfused fontanelles; neurologic findings after significant brain injury usually appear just
before herniation; patients <2 yr of age—higher incidence of intracranial injury than in older children; use low
threshold for CT and have higher clinical suspicion for TBI; clinical signs and poor predictors—include supple hematoma;
in children >2 yr of age, risk factors for intracranial injury include anticoagulation, abnormal mental status,
and trauma above clavicles; in children <2 yr of age, risk factors for intracranial injury include significant mechanism
(eg, fall >3 ft), abnormal score for modified GCS, abnormal or age-inappropriate behavior, and significant scalp soft
tissue injuries; obtain CT if skull fracture suspected; skull x-rays not recommended
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| Management: important considerations—identify TBI and get neurosurgical evaluation without delay; prevent secondary
brain injury; malpractice claims arise from treatment delay and improper management; guidelines—recommend
early neurosurgical evaluation; use hyperventilation and mannitol to decrease intracranial pressure (ICP) quickly only
if patient shows signs of herniation; hyperventilation quick and effective in decreasing ICP, but can decrease oxygen
supply to brain and result in worsened outcome; avoid steroids in TBI; consider posttraumatic seizure prophylaxis if
blood accumulates on cerebral cortex, especially if neurosurgcal evaluation delayed or seizure occurs
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| Missed injuries: frequency of claims in malpractice, 2%; usually due to lack of physical examination or radiologic studies
or reliance on plain films or use of lateral view only for diagnosis; cervical spine series—3-view x-ray series standard
of care to clear patient; immobilization collar and “somewhat supine” position required until patient cleared; x-ray
films frequently misinterpreted and have poor sensitivity; lack of timely over-read and x-ray discrepancy important cause
of missed injuries; radiologist should communicate discrepancy within 24 hr; call radiologist for input on interpreting x-
ray series; patients with subtle or transient neurologic symptoms should get CT or magnetic resonance imaging (MRI),
not x-ray; frequency of claims 2%, but 6% of dollars paid; study reviewed 549 closed claims and found 6 cases with indemnities
>$1 million; claims over policy limits can lead to seizure of personal assets
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| Patient evaluation: high-risk mechanisms of injury include fall from height, motorcycle crash, pedestrian involvement
in accident, ejection from vehicle during MVA, and MVA with rollover; get description of pain, associated signs and
symptoms, and thorough history; urinary incontinence—initially, urinary retention, not incontinence, seen in patients
with spinal cord injuries, eg, cauda equina syndrome (unless urinary retention results in overflow incontinence); urinary
retention and fecal incontinence seen in patient with spinal cord injury; physical examination—take good look at vertebral
column; perform thorough neurologic examination; palpate each vertebral body and spinous process and determine
origin of pain (paraspinal or midline); in patient (especially elderly patient) complaining of neck pain, lack of tenderness
on palpation of cervical spine does not indicate lack of injury
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| Clinical decision rules: combination of National Emergency X-Radiography Utilization Study (NEXUS) criteria for
cervical spine clearance and Canadian Cervical Spine Rule best approach; NEXUS criteria for clearing cervical
spine—include absence of posterior midline neck tenderness, altered mental status, distracting injuries and neurologic
deficits; age and mechanism of injury not included; NEXUS included >34,000 patients and found 818 spinal injuries
(2.4% incidence); 236 patients who had cervical spine injury (CSI) met only one criterion, ie, midline tenderness; decision
rule sensitivity 99%; study missed 8 injuries, but only 2 clinically significant (of which 1 old injury); 336 patients
with blunt trauma had distracting injury requiring x-ray; long bone fracture occurred in all patients with distracting injury
and CSI; NEXUS did not define “distracting injury”; Canadian Cervical Spine Rule—if patient can actively rotate
neck 45° to right and left, cervical spine clear; imaging required in high-risk patients, eg, >65 yr of age, with degenerative
joint disease (DJD), or with high-risk mechanism of injury (eg, MVA rollover); speaker recommends using NEXUS
rules for clearance, using good clinical judgment, and imaging patients at high risk or if mechanism of injury associated
with high risk for CSI; Canadian rule based on 9000 patients and 100% sensitive for predicting CSI
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| Imaging studies: 3 x-ray views of cervical spine standard; anterior vertebral body line, posterior vertebral body line,
spinolaminar line, and posterior spinous process line should line up; C1, C2, and C3 should line up on spinolaminar line;
obtain CT if not aligned; factors in misdiagnosis—radiographic study not done; reliance on cross-table view alone;
misinterpretation of x-rays; inadequate x-ray films; noncontiguous fractures—patients with cervical spine fracture
likely to have second or third fracture; potential for noncontiguous fracture; send patient for CT if fracture found, so second
or third fractures not missed; mental status—can miss injuries in intoxicated or head-injured patients because of inadequate
assessment; bilateral facet dislocation—unstable injury; significant ligamentous injury; avoid 45° test in
these patients; flexion-extension x-rays—worthless test, but not harmful; unstable ligamentous injury without radiographic
abnormalities rare (x-ray usually prompts MRI or CT); while performing rotation test, have patient actively lift
head (do not push head past comfortable range of motion); inadequate flexion-extension can occur in patient in pain; get
MRI or CT or call neurosurgery if concerned; unnecessary in patient with normal 3-view cervical spine x-rays and normal
movement
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| Criteria for imaging and treatment decisions: 1999 radiology study—found 3-view series good screening test
and reliable in mild to moderately injured patients; CT provides additional layer for diagnosis in patients with possible
fractures; 2005 study—found sensitivity of x-rays 52% and sensitivity of CT 98%; study looking at role of CT in evaluation
of CSI, so not good screening test but tolerated in low-risk patients; 1999 study—recommended CT as screening
examination in cases of inadequate cervical spine series and if patient at high risk for CSI; 2003 study—found sensitivity
of x-rays worse in patients with altered mental status; study involving 172 injuries identified in 116 patients; compared
CT to 5-view cervical spine series; x-rays failed to identify 52% of fractures, and 17% of missed injuries unstable;
CT missed minimal injuries and all patients deemed stable; persistent neurologic complaints—require MRI; consider
consulting neurosurgery
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| Pediatric spinal injuries: spinal injuries rare in patients <18 yr of age, especially in patients <8 yr of age; look for injuries
at C1 to C4 in patients <8 yr of age; study data—looking at 6800 children, found CSI in 0.8%; false positives occurred
at C1 and C2; most false positives at C2 identified as C2 on C3 pseudosubluxation (developmental issue; possibly
normal variant); 2001 study—looking at mechanism of injury found 52% of CSIs related to MVA, and 27% related to
sporting injuries; 38% of spinal injuries in children identified as spinal cord injury without radiographic abnormality
(SCIWORA); 75% of SCIWORA related to sporting injuries, and some occurred in infants as result of child abuse; fractures
commonly due to falls or dives (high-risk behavior associated with adolescence); location of CSI—68% of injuries
in patients <6 yr of age C1 to C4 (cannot palpate at C1 and possibly not C2); injuries at both levels occurred in 7% (eg,
noncontiguous injury); SCIWORA—more common in children than in adults; involves normal neurologic examination
or potentially abnormal examination and normal x-rays; obtain MRI; children benefit from early surgical intervention
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| Cervical spine clearance: clinical decision rules met; if adequate 3-view cervical spine series normal, low-risk patient
cleared; do thorough examination; repeat examinations; consider whether patient’s condition changing, and manage appropriately;
if significant concerns exist, keep collar on; do not clear patients with altered mental status, even if CT normal
(eg, keep collar on until intoxicated patient sober; high-risk issue); study—concluded that patient with altered
mental status for 3 days with negative CT should get MRI at day 3; if no neurologic deficits present and MRI negative,
clear patient, even if mental status still altered; thoracic and lumbar spine—same indications as for cervical spine; CT
indicated in high-risk patients, eg, ankylosing spondylitis, rheumatoid arthritis, multiple medical problems, or high-risk
age group; get CT of entire spine to look for other fractures in patients with spinal injury; steroids—study found no clinical
benefit to use of steroids in CSI; however, consider steroid use to lower legal risk; if not providing steroids to patient,
document reason in chart and consider getting input from neurosurgery; airway management—consider if benefit outweighs
risk; do orotracheal intubation with in-line stabilization
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| Case 1: intoxicated man 72 yr of age (well known to staff) fell and struck head; nasal injury; abrasions on right arm; toxicology
screen, head CT, and shoulder screen negative; discharge order written, but patient could not sit up; generalized
and focal right-sided weakness; diagnosis of stroke made, and patient admitted; cervical spine films ordered 48 hr after
admission showed fracture at C7 as cause of neural deficits; patient died; risk management issues—NEXUS standard
of care not followed; cervical spine never immobilized; failure to recognize or consider cervical spine injury as cause of
neurologic symptoms; monetary settlement
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| Case 2: obese man (>300 lb); unrestrained driver in MVA (double rollover); had transient LOC; in full spinal immobilization;
patient having difficulty breathing because of uncomfortable position; CT of head negative; to facilitate getting patient
into scanner, collar removed (patient previously “cleared to C5”); patient made to walk to another room in CT suite;
upon return from CT, nurse noted patient had decreased sensation; at shift change, new physician found patient had only
muscle twitch; full spinal immobilization resumed and steroid administered; risk management issues—failure to maintain
spinal immobilization; patient ambulated without cervical spine clearance; inadequate reassessment; large monetary
settlement
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Suggested Reading
Barrett TW et al: Injuries missed by limited computed tomographic imaging of patients with cervical spine injuries. Ann
Emerg Med 47:129, 2006; Barry TB et al: Clinical decision rules and cervical spine injury in an elderly patient: a word
of caution. J Emerg Med 29:433, 2005; Bazarian JJ et al: Emergency department management of mild traumatic brain
injury in the USA. Emerg Med J 22:473, 2005; Blackwell CD et al: Pediatric head trauma: changes in use of computed
tomography in emergency departments in the United States over time. Ann Emerg Med 49:320, 2007; Garra G et al: Minor
head trauma in anticoagulated patients. Acad Emerg Med 6:121, 1999; Griffen MM et al: Radiographic clearance of
blunt cervical spine injury: plain radiograph or computed tomography scan? J Trauma 55:222, 2003; Hassan Z et al:
Head injuries: a study evaluating the impact of the NICE head injury guidelines. Emerg Med J 22:845, 2005; Hendey GW
et al: Spinal cord injury without radiographic abnormality: results of the National Emergency X-Radiography Utilization
Study in blunt cervical trauma. J Trauma 53:1, 2002; Knopp R: Comparing NEXUS and Canadian C-Spine decision rules
for determining the need for cervical spine radiography. Ann Emerg Med 43:518, 2004; Mack LR et al: The use of head
computed tomography in elderly patients sustaining minor head trauma. J Emerg Med 24:157, 2003; Palchak MJ et al:
A decision rule for identifying children at low risk for brain injuries after blunt head trauma. Ann Emerg Med 42:492, 2003;
Sanchez B et al: Cervical spine clearance in blunt trauma: evaluation of a computed tomography-based protocol. J
Trauma 59:179, 2005; Vilke GM et al: Use of a complete neurological examination to screen for significant intracranial
abnormalities in minor head injury. Am J Emerg Med 18:159, 2000.
Educational Objectives
| The goal of this activity is to improve the management of traumatic head, neck, and spine injuries in adults and children.
After hearing and assimilating this program, the clinician will be better able to:
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| 1. Evaluate an adult patient with minor head injury for traumatic brain injury.
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| 2. Evaluate a pediatric patient with head injury for intracranial injury.
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| 3. Identify cervical spine injuries (CSI) in adults and children.
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| 4. Discuss use of computed tomography and magnetic resonance imaging to evaluate a patient for CSI.
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| 5. Describe the differences between the National Emergency X-Radiography Utilization Study (NEXUS) rules
and the Canadian Cervical Spine Rule for cervical spine clearance.
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Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty members to disclose relevant
financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified
conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business
or commercial interest. For this program, the faculty reported nothing to disclose.
Acknowledgements
Dr. Klauer was recorded in Las Vegas, NV, at High Risk Emergency Medicine, held April 6-9, 2007, and sponsored
by the Center for Emergency Medical Education. The Audio-Digest Foundation thanks the speaker and the sponsor
for their cooperation in the production of this program.
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