Prehospital stabilization of the cervical spine for penetrating injuries of the neck — is it necessary?
Introduction
The question of whether to stabilize the cervical spine during the initial management of a trauma victim who has sustained a penetrating neck injury, has recently stirred debate and controversy among trauma surgeons and neurosurgeons in our country. The trigger was a few cases in which a semi-rigid collar was applied over a penetrating injury, usually due to high velocity bullets or projectiles. Findings such as continuous oozing, subcutaneous emphysema and especially expanding haematoma were initially missed.
Current literature does not directly address the indications, benefit and risk concerning so-called immobilization for penetrating neck injuries. This is true for both journals [1], [2], [3], [4], [5], [6], [7] and major trauma textbooks [8], [9], [10], [11], [12]. Most authors simply recommend that all patients with such injuries should be immobilized, or merely state that such is the practice in their emergency department and pre-hospital trauma care. Even the manual of the ATLS® [13] does not make a distinction between blunt and penetrating neck trauma, generally stating that “…any patient with a suspected spine injury must be immobilized above and below the suspected injury site until injury has been excluded by roentgenograms”. In addition it stresses that “…cervical spine injury requires continuous immobilization of the entire patient with a semi-rigid cervical collar, backboard, tape and straps before and during transfer to a definite-care facility”. In depth analysis of the text following these statements reveals that the author is referring only to casualties from blunt injury!
In this study we try to assess the benefit and risk of cervical spine stabilization in penetrating neck injury. New management guidelines for penetrating neck injuries at the pre-hospital setup are suggested.
Section snippets
Materials and methods
During the period from January 1993 to June 1997, 54 soldiers of the Israeli army were diagnosed in the field as having a penetrating neck injury. All injuries involved gunshot, projectiles or stab wounds. Military physicians on site performed the initial assessment and began treatment.
Current guidelines in the Israeli Army Medical Corps, based on ATLS, call for early stabilization of the cervical spine for every suspicion of significant neck injury. Accordingly, in all cases in this series a
Results
Forty-four hospital and autopsy charts were available for analysis, out of a total of 54 injuries during the study period of 4.5 years. Most injuries were due to projectiles (38), or bullets (13). Knife injuries (2 cases), and direct missile hits were a rare occurrence. Table 1, Table 2 show the distribution of injuries and important signs for the 44 cases we studied. Table 3 shows the treatment performed for the 36 cases that were transported to a hospital.
All patients who were admitted to a
Discussion
Some trauma surgeons question the indications for cervical spine stabilization during the initial management of a penetrating neck injury. Apparently there is no definite answer in the literature. We believe that the current “standard of care”, the application of a rigid or semi-rigid cervical collar, has evolved inadvertently from the universally accepted procedure for blunt trauma casualties. The risks of rigid/semi-rigid collar application over a penetrating injury justify, to our
Conclusions
We, therefore, conclude that the current routine of pre-hospital stabilization of the neck in penetrating trauma using a collar and additional devices should be seriously re-evaluated. Avoiding the collar should be the rule, and a very good point should be made for applying the device to justify the risk.
The following guidelines are hereby suggested:
- 1.
In penetrating injury to the neck without a clear neurological deficit, there is no place for using a collar or any other device for neck
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