A 25-year-old man is brought to the emergency department after he fell headfirst down a flight of stairs while intoxicated. According to friends who witnessed the fall, the patient landed on his head but did not lose consciousness. On arrival, blood pressure is 128/78 mm Hg, pulse is 92/min, and respirations are 12/min. The patient smells of alcohol and is somnolent but can follow simple commands. There are facial abrasions. A rigid cervical collar is in place. Bilateral breath sounds are normal with no chest tenderness. Heart sounds are normal. The abdomen is soft and nontender. The patient is moving all extremities spontaneously. He states that he is uncomfortable due to the cervical collar and requests that it be removed. Which of the following is the best immediate step for evaluating and ruling out cervical spine injury in this patient?

Question

A 25-year-old man is brought to the emergency department after he fell headfirst down a flight of stairs while intoxicated.  According to friends who witnessed the fall, the patient landed on his head but did not lose consciousness.  On arrival, blood pressure is 128/78 mm Hg, pulse is 92/min, and respirations are 12/min.  The patient smells of alcohol and is somnolent but can follow simple commands.  There are facial abrasions.  A rigid cervical collar is in place.  Bilateral breath sounds are normal with no chest tenderness.  Heart sounds are normal.  The abdomen is soft and nontender.  The patient is moving all extremities spontaneously.  He states that he is uncomfortable due to the cervical collar and requests that it be removed.  Which of the following is the best immediate step for evaluating and ruling out cervical spine injury in this patient?

Quizplus · Accepted Answer

Explanation: This patient who fell headfirst down a flight of stairs and landed on his head may have a cervical spine (CS) injury. Patients at high risk of CS injury (eg, high-energy mechanism, trauma causing concomitant closed head injury) automatically require CS imaging. Other patients, such as this one, who have a less severe trauma mechanism but some risk for CS injury are managed according to clinical decision rules such as the National Emergency X-Radiography Utilization Study (NEXUS) low-risk criteria. According to these criteria, CS imaging is necessary if any of the following is present: Neurologic deficit Spinal tenderness Altered mental status Intoxication Distracting injury This patient is both somnolent and intoxicated; therefore, CS imaging is indicated. A CT scan of the CS without contrast is the preferred screening test to evaluate for CS injury, especially for fracture, because it is significantly more sensitive than plain radiography (ie, ~98% vs ~52% sensitivity) (Choice D). If none of the NEXUS criteria are present, then imaging is not required; a normal neurologic examination is sufficient to rule out CS injury and remove the collar (Choice E). (Choice B) Flexion and extension x-rays are lateral views taken during CS flexion and extension to assess for ligamentous injury. However, these views are not performed until after a CS fracture has been ruled out (eg, with a negative CT scan) and can be performed safely only in alert, cooperative patients (vs this somnolent, intoxicated patient). (Choice C) MR imaging is not commonly performed as the primary screening test for CS injury; instead, it is typically performed when a CT scan suggests ligamentous or spinal cord injury, in order to better visualize the soft tissues. CT scan is quicker, cheaper, and better tolerated by patients than MRI. Educational objective: CT scan is the preferred test to screen for cervical spine injury. Indications include high-energy mechanism of injury or any of the following findings: neurologic deficit, spinal tenderness, altered mental status, intoxication, or distracting injury. References: Emergency department evaluation and treatment of cervical spine injuries. (http://www.ncbi.nlm.nih.gov/pubmed/25892721) Practice management guidelines for identification of cervical spine injuries following trauma: update from the Eastern Association for the Surgery of Trauma practice management guidelines committee. (http://www.ncbi.nlm.nih.gov/pubmed/19741415)

A 25-Year-Old Man Is Brought to the Emergency Department After