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Prehospital Spine Immobilization for Penetrating Trauma—Review and Recommendations from the Prehospital Trauma Life Support Executive Committee

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Prehospital Spine Immobilization for Penetrating Trauma—Review and Recommendations from the Prehospital Trauma Life Support Executive Committee REVIEW ARTICLE Prehospital Spine Immobilization for Penetrating Trauma—Review and Recommendations From the Prehospital Trauma Life Support Executive Committee Lance E. Stuke, MD, MPH, Peter T. Pons, MD, Jeffrey S. Guy, MD, MSc, MMHC, Will P. Chapleau, RN, EMT-P, Frank K. Butler, MD, Capt MC USN (Ret), and Norman E. McSwain, MD pine immobilization in trauma patients suspected of hav- In the case of penetrating injuries, delays in transport Sing a spinal injury has been a cornerstone of prehospital prolong the time before patients receive the prompt surgical treatment for decades. Current practices are based on the care needed to arrest hemorrhage. Even with experienced belief that a patient with an injured spinal column can prehospital providers, spine immobilization is time consum- deteriorate neurologically without immobilization. Most ing. The time required for experienced emergency medical treatment protocols do not differentiate between blunt and technicians to properly immobilize a cervical spine has been penetrating mechanisms of injury. Current Emergency Med- reported to be 5.64 minutes (Ϯ1.49 minutes).6 This scene ical Service (EMS) protocols for spinal immobilization of delay can be catastrophic for a patient with penetrating penetrating trauma are based on historic practices rather than trauma requiring urgent surgical intervention for airway com- scientific merits. Although blunt spinal column injuries will promise or hemorrhage. Studies have demonstrated that cervical collars increase occasionally produce unstable vertebral injuries, which may 7–9 result in subsequent neurologic propagation if not managed intracranial pressure in patients with head injuries. The mechanism for this rise in intracranial pressure is unknown appropriately in the field, this has not been demonstrated to but has been postulated to be due to jugular venous compres- be the case with penetrating trauma.1 sion by the cervical collar.10 Finally, no study has demon- Patients with penetrating trauma have different man- strated that penetrating trauma can produce an unstable spine agement priorities than those with blunt mechanisms. In injury. Progression of spinal cord injury has not been dem- patients with penetrating wounds of the head and neck, cervical onstrated to occur following penetrating trauma, which has a collars hinder provider assessment of the neck for evolving different mechanism of injury from blunt trauma. injuries, tissue edema, subcutaneous emphysema, hema- The PreHospital Trauma Life Support (PHTLS) pro- toma development or expansion, and tracheal deviation— gram is a national and international educational effort spon- with many of these injuries often identified only after sored jointly by the National Association of Emergency removal of the cervical collar.2,3 Medical Technicians and the American College of Surgeons Airway management is a significant issue in the pene- Committee on Trauma. The Executive Committee of PHTLS trating trauma population who have had their cervical spine is comprised of surgeons, emergency physicians, and para- immobilized by prehospital personnel. Endotracheal intuba- medics. The mission of PHTLS is to further the knowledge of tion is more difficult in patients with cervical immobiliza- prehospital providers of all levels in the management of tion.4 More attempts at intubation occur in patients with victims of trauma. To that end, PHTLS publishes textbooks cervical spine immobilization than occur without, and there is and offers educational courses for prehospital providers at a higher incidence of esophageal intubation and tube dis- both basic and advanced levels of training. The PHTLS lodgement in this group.5 program was modeled after the American College of Sur- geons Committee on Trauma Advanced Trauma Life Support course for physicians. Submitted for publication February 1, 2011. Accepted for publication May 19, 2011. Copyright © 2011 by Lippincott Williams & Wilkins MATERIALS AND METHODS From the Department of Emergency Medicine (P.T.P.), Denver Health Medical Center, Denver, Colorado; Department of Surgery (J.S.G.), Vanderbilt Uni- A literature search was done of the National Library of versity School of Medicine, Nashville, Tennessee; American College of Medicine and the National Institutes of Health MEDLINE Surgeons (W.P.C.), Chicago, Illinois; Committee on Tactical Combat Casu- database using PubMed (www.pubmed.gov). The search re- alty Care (F.K.B.), Defense Health Board, Washington, D.C.; and Department of Surgery (N.E.M.), Tulane University School of Medicine, New Orleans, trieved English language articles from 1989 through 2011 Louisiana. relevant to the identification and prehospital management of Address for reprints: Lance E. Stuke, MD, MPH, Department of Surgery, spine injuries as a result of penetrating trauma. MeSH search Louisiana State University Health Sciences Center at New Orleans, 1542 terms included “prehospital,” “cervical spine,” “spine in- Tulane Avenue 734, New Orleans, LA 70112; email: [email protected]. jury,” and “penetrating trauma.” Letters to the editor were DOI: 10.1097/TA.0b013e3182255cb9 excluded. The Cochrane Library online database was also The Journal of TRAUMA® Injury, Infection, and Critical Care • Volume 71, Number 3, September 2011 763 Stuke et al. The Journal of TRAUMA® Injury, Infection, and Critical Care • Volume 71, Number 3, September 2011 queried for systematic reviews of prehospital cervical spine an unstable spine fracture which ultimately required interven- immobilization and emergency intubation.11,12 tion. The neurologic examination on this patient is not doc- Bibliographies of all reviewed articles were crossrefer- umented in the article—he was in cardiac arrest at the time of enced to locate any relevant articles not located in the MeSH arrival, resuscitated, had a Halo placed, and died 3 days later search. Articles were selected by one reviewer and confirmed of an associated injury. Another review of 44 military casu- for relevancy by a second author. Final review was completed alties from Israel noted similar results.2 An analysis of 24,246 by a third author and any disagreement in selection of articles trauma patients from 2 civilian centers noted 165 patients was arbitrated by this author. The questions posed by the with a cervical spine fracture from a gunshot wound (GSW), reviewers in selecting the articles were (1) what is the of which 114 had a spinal cord injury.18 They also noted nine incidence of unstable spine fracture and spinal cord injury in patients with a stab wound to the neck, six of which had a the penetrating trauma patient?; (2) what is the natural history spine injury. All patients in their series who had spinal cord of spinal cord injury in penetrating trauma (i.e., does the injury had a noted neurologic deficit at presentation. Spine neurologic deficit worsen over time with or without spine fixation, either surgically or with a Halo, did not improve immobilization)?; and (3) is spine immobilization necessary their neurologic status. The frequency of a neurologically in cases of penetrating trauma? intact patient requiring cervical neck stabilization after a The system for classification criteria for medical GSW was only 0.03%. A recent single center review of 1,069 evidence (Table 1) proposed by Wright et al.13,14 has been patients sustaining penetrating neck trauma noted only a chosen by the PHTLS Executive Committee for our use to 0.4% incidence of unstable cervical spine injury.21 Neck classify medical evidence. This system has also been GSW’s resulted in a less than 1% incidence of unstable adopted by the 8th edition Advanced Trauma Life Support cervical spine injury, and there were no documented unstable course as well as several prominent journals. It is easy to cervical spine injuries from stab wounds. All patients who interpret and has been shown to have a high rate of had an unstable fracture had obvious neurologic deficits or an interrater agreement.15,16 altered mental status on arrival. Four articles focused specifically on penetrating trauma RESULTS to the head.4,5,24,25 In these studies, 524 total patients were Twenty articles met criteria and were included in the reviewed who had an isolated GSW to the cranium, many of study. These results are summarized in Table 2. Eight articles whom underwent spinal immobilization out of the concern focused on isolated penetrating trauma to the neck.2,17–23 One for possible spine injury. No incidence of cervical spine study of military combat casualties noted that 70% of patients injury was noted among these patients. Hypoxia is known to with cervical spine fractures from penetrating trauma also had worsen neurologic injury in patients with head trauma. En- a major vascular injury.22 Only 1 in 56 survivors (1.8%) had dotracheal intubation was significantly more difficult in pa- TABLE 1. Levels of Evidence13,14 Level of Economic and Decision Evidence Treatment Prognosis Diagnosis Analysis 1 RCT with significant difference Prospective study with single Testing of previously applied diagnostic Clinically sensible costs and or narrow confidence inception cohort and criteria in a consecutive series against alternatives intervals Ͼ80% follow-up a gold standard Values obtained from many studies Systematic reviews of level 1 Systematic review of level 1 Systematic review of level 1 studies Multiway sensitivity analyses studies studies Systematic review of level 1 studies 2 Prospective cohort, poor Retrospective study Development of diagnostic criteria on Clinically sensible
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