Ah, the “distracting” injury. An utterly subjective and modifiable component of cervical spine clearance in the NEXUS criteria. Is it an isolated finger dislocation? Is it a femur fracture? We’ve all seen patients writhing or stoic in the face of either. And, then, factor in any prehospital analgesia ….
This is a prospective, observational study coming out of the American Association for the Surgery of Trauma evaluating the effects of distracting injury on cervical spine clearance. For their purposes, the following injuries were considered “distracting”:
Skull fracture, >2 facial bone fractures, mandible fracture, intracranial hemorrhage (including subdural hematoma, epidural hematoma, subarachnoid hemorrhage, intraventricular hemorrhage, intraparenchymal hematoma), >2 rib fractures, clavicle fracture, sternal fracture, pelvic fracture, thoracolumbar spine fracture, intra-abdominal injury (including solid organ injury, hollow viscus injury, or diaphragmatic injury), femur fracture, tibia/fibula fracture, humerus fracture, radius/ulna fracture, and hip or shoulder dislocation.
The physical exam consisted of midline neck palpation and, absent any contraindication, active range of motion of the neck in flexion, extension and rotation. The cervical collar could be removed at the discretion of the treating team, but – in classic traumatology fashion – all patients underwent CT of the cervical spine, regardless of exam.
There were 2,929 blunt trauma patients with GCS ≥14, and 222 had cervical spine injuries identified on CT. Of these injuries, 25 were “missed” by the clinical exam. The “good news”: the rate of miss was “the same”, regardless of distracting injury – 0.7% vs. 1.3%. The bad news, of course, is that a normal physical examination missed 11% of cervical spine injuries. One patient whose injury would have otherwise been missed by a negative physical examination underwent operative intervention.
While there is some obvious spectrum bias associated with any observational cohort enrolled at trauma centers, it is still a reasonable estimate of the sensitivity and specificity of the physical examination. Clearly, it’s not bulletproof in the context of multi-system trauma – but, depending on the pretest likelihood of a cervical spine injury based on other presenting features, a distracting injury need not disqualify a patient from clinical clearance.
“Clearing the Cervical Spine in Patients with Distracting Injuries: An AAST Multi-Institutional Trial”
Not sure what to make of this. No SS difference based on their definition of disrdcting injury, but huge miss rate (although only one that required surgery). Biggest concern for me is the concept that injuries qualifying as DI needs to be defined – they can’t be. It’s individualized. Is the pt in front of me so distracted by this other painful injury that they won’t notice the pain when I push on their broken neck? That depends on the patient, not on what their injury is.