NICE SPINAL INJURY GUIDELINES, RCEM FOAMed

March 15, 2017

 

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This month Becky and Chris explore the 2016 NICE guidance on the management of suspected spinal injury.

Now these guidelines came out in the early part of 2016 and have had a great summary produced by the St Emlyn’s guys. This month we’re really drilling down in to the specifics around suspected spinal injury in major trauma.

Since our training began we’ve had the ATLS mantra of 3 point C-spine immobilisation well and truly drilled into us for all trauma patients, this guideline is an update on how we should manage spinal trauma in the modern world…..is the c-spine collar confined to the bin? Well, No.

Whether working in the pre-hospital setting or in the ED it is important to approach your trauma patient with an A-E assessment. Nothing ground breaking here. Rapidly assess and treat immediately life threatening injuries, working in a well oiled well rehearsed trauma team would be ideal.

Manual in line stabilisation (MILS) is recommended from the outset, moving on to full spinal immobilisation if there are nay high risk features

1: Distracting injury – this is hard to define and we all have different thresholds for what constitutes distraction. Let us know your thoughts on this in the comments below!!

2: Drunk and intoxicated – this is fair game in our eyes.

3: Those with neurological deficit, again we both agreed this would be fair to try and reduce any chance (if slight movement could increase the chance) of a deterioration. We both hold our hands up to not looking for and documenting the presence or absence of priapism as part of that neuro exam – do you?

When assessing someone’s C-spine NICE recommends the Canadian C-spine rules. (Nikki Abela sheds some light on them in the context of kids here too).

In those who are deemed to require imaging – CT is the weapon of choice. For all of them. Let that sink in. Now think about your radiology dept….

We both still work in places where not EVERY c-spine is sent for CT although the frequency of C-spine tri-series x-rays has reduced massively.

What happens in your place? CT for all? Let us know!

Immobilisation

When immobilising the guidance is relatively pragmatic: – ‘tailor it to the patient’

Recognise thick/shirt necks could be hard.

Recognise that immobilisation could worsen pain or neurological symptoms.

If your patient is agitated/distressed consider allowing them to find their own position and adopt MILS.

This is great advice – and mirrors my personal approach to anyone in a collar and tapes- remember that someone fighting against immobilisation could well be moving their neck more than you want, and fulcrumming against the collar at C7. There was a great proof of concept in a paper published in the EMJ back in 2010 which discussed some of the potential harms of C-spine collars (Holla 2010).

NICE still recommends however a step-wise approach –

Collar: semi rigid, except if airway compromise or spinal deformity– again great advice – seeing fewer old kyphotic ladies coming in immobilised has to be a win! I guess the question is still whether anyone who is concious needs a collar?

There’s been some great work out of Bristol from Prof Benger and Jules Blackham on this topic and we’d love you to share your practice with us.

In addition to a collar – if you’re putting one on – then add a vacuum mattress or a sandbags/tape device.

In summary

  • The assessment process makes sense.
  • Some nice pragmatism on immobilisation strategies IMHO.
  • The use of the Canadian C-spine rues is the way to go.
  • CT is the imaging of choice if you need to scan. Probably. Although the increased burden on imaging departments is likely to be huge!!

Thanks for listening

Chris & Becky

References

 

Value of a rigid collar in addition to head blocks: a proof of principle study. Holla EMJ 2010)

Unstable Spinal Fractures in Snowdonia Mountain Casualties. J Hunt, L Dykes, T Walford EMJ 2016

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