Cervical spine evaluation and clearance in the intoxicated patient: A prospective Western Trauma Association Multi-Institutional Trial and Survey

被引:30
作者
Martin, Matthew J. [1 ]
Bush, Lisa D. [1 ]
Inaba, Kenji [2 ]
Byerly, Saskya [2 ]
Schreiber, Martin [3 ]
Peck, Kimberly A. [4 ]
Barmparas, Galinos [5 ]
Menaker, Jay [6 ]
Hazelton, Joshua P. [7 ]
Coimbra, Raul [8 ]
Zielinski, Martin D. [9 ]
Brown, Carlos V. R. [10 ]
Ball, Chad G. [11 ]
Cherry-Bukowiec, Jill R. [12 ]
Burlew, Clay Cothren [13 ]
Dunn, Julie [14 ]
Minshall, C. Todd [15 ]
Carrick, Matthew M. [16 ]
Berg, Gina M. [17 ]
Demetriades, Demetrios [2 ]
Long, William [1 ]
机构
[1] Legacy Emanuel Med Ctr, Portland, OR USA
[2] LAC USC Med Ctr, Los Angeles, CA USA
[3] Oregon Hlth & Sci Univ, Portland, OR 97201 USA
[4] Scripps Mercy Hosp, San Diego, CA USA
[5] Cedars Sinai Med Ctr, Los Angeles, CA 90048 USA
[6] R Adams Cowley Shock Trauma Ctr, Baltimore, MD USA
[7] Cooper Univ Hosp, Camden, NJ USA
[8] Univ Calif San Diego, La Jolla, CA 92093 USA
[9] Mayo Clin, Rochester, MN USA
[10] Univ Med Ctr Brackenridge, Austin, TX USA
[11] Univ Calgary, Foothills Med Ctr, Calgary, AB, Canada
[12] Univ Michigan, Ann Arbor, MI 48109 USA
[13] Denver Hlth Med Ctr, Denver, CO USA
[14] Univ Colorado, Hlth Med Ctr Rockies, Loveland, CO USA
[15] Univ Texas Southwestern Med Ctr Dallas, Parkland Mem Hosp, Dallas, TX 75390 USA
[16] Med Ctr Plano, Plano, TX USA
[17] Wesley Med Ctr, Wichita, KS USA
关键词
Cervical spine; cervical collar; intoxication; alcohol; drugs; BLUNT TRAUMA; COMPUTED-TOMOGRAPHY; INTRACRANIAL-PRESSURE; ALCOHOL-INTOXICATION; EASTERN ASSOCIATION; LIGAMENTOUS INJURY; COLLAR; MRI; RULE; MANAGEMENT;
D O I
10.1097/TA.0000000000001650
中图分类号
R4 [临床医学];
学科分类号
1002 ; 100602 ;
摘要
BACKGROUND Intoxication often prevents clinical clearance of the cervical spine (Csp) after trauma leading to prolonged immobilization even with a normal computed tomography (CT) scan. We evaluated the accuracy of CT at detecting clinically significant Csp injury, and surveyed participants on related opinions and practice. METHODS A prospective multicenter study (2013-2015) at 17 centers. All adult blunt trauma patients underwent structured clinical examination and imaging including a Csp CT, with follow-up thru discharge. alcohol- and drug-intoxicated patients (TOX+) were identified by serum and/or urine testing. Primary outcomes included the incidence and type of Csp injuries, the accuracy of CT scan, and the impact of TOX+ on the time to Csp clearance. A 36-item survey querying local protocols, practices, and opinions in the TOX+ population was administered. RESULTS Ten thousand one hundred ninety-one patients were prospectively enrolled and underwent CT Csp during the initial trauma evaluation. The majority were men (67%), had vehicular trauma or falls (83%), with mean age of 48 years, and mean Injury Severity Score (ISS) of 11. The overall incidence of Csp injury was 10.6%. TOX+ comprised 30% of the cohort (19% EtOH only, 6% drug only, and 5% both). TOX+ were significantly younger (41 years vs. 51 years; p < 0.01) but with similar mean Injury Severity Score (11) and Glasgow Coma Scale score (13). The TOX+ cohort had a lower incidence of Csp injury versus nonintoxicated (8.4% vs. 11.5%; p < 0.01). In the TOX+ group, CT had a sensitivity of 94%, specificity of 99.5%, and negative predictive value (NPV) of 99.5% for all Csp injuries. For clinically significant injuries, the NPV was 99.9%, and there were no unstable Csp injuries missed by CT (NPV, 100%). When CT Csp was negative, TOX+ led to longer immobilization versus sober patients (mean, 8 hours vs. 2 hours; p < 0.01), and prolonged immobilization (>12 hrs) in 25%. The survey showed marked variations in protocols, definitions, and Csp clearance practices among participating centers, although 100% indicated willingness to change practice based on these data. CONCLUSION For intoxicated patients undergoing Csp imaging, CT scan was highly accurate and reliable for identifying clinically significant spine injuries, and had a 100% NPV for identifying unstable injuries. CT-based clearance in TOX+ patients appears safe and may avoid unnecessary prolonged immobilization. There was wide disparity in practices, definitions, and opinions among the participating centers. LEVEL OF EVIDENCE Diagnostic tests or criteria, level II.
引用
收藏
页码:1032 / 1040
页数:9
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