Category: Trauma

Cervical Spine Clearance in the trauma patient

Although in ED we cannot prevent the primary injury, our objective is to recognise and prevent secondary injury. Through the use of the agreed standards

Standards:

  1. Spinal protection must remain in place if an injury is suspected/identified, or until it is excluded via an established protocol.
    • Unless a senior clinician has clearly documented a decision, immobilisation not in the patients best interest.
  2. Assessment of the whole spine should be performed and documented where injury is suspected.
  3. If abnormal clinical signs are found, complete neurological examination must be performed and documented.
  4. If spinal injury identified OR abnormal neurological signs consistent with spinal cord injury are found, immediate discussion with and referral to a centre capable of emergency spinal surgery must occur.
  5. Significant spinal injury is excluded following either:
    • Normal clinical examination in an awake and orientated patient with no clinically significant distracting injury OR illness is present; the patient can concentrate on and reliably report neck findings. (in line with Canadian C-Spine rules)
    • Completion of spinal imaging protocols (standard 6).
  6. Imaging protocols:
    • Thoracic and lumbar spine scans should be obtained according to major trauma protocols.If a cervical spine injury is suspected, thin slice CT scanning from occiput to T4, including sagittal and coronal reconstructions should be performed without delay.If whole-body CT (WBCT) for trauma is necessary, this should include the cervical spine if injury is suspected.
    • An initial report of spine clearance imaging should be available before the patient leaves the Emergency Department.
OptionScenarioAction
1This investigation demonstrates an injury that may affect spinal stability. (see Notes)Continue spinal protection and seek advice from an appropriate clinical team. 
2This scan is of good quality and there are no comorbidities confounding its interpretation. No features of instability, such as fracture, haematoma or joint disruption are seen.Patients with NO acute neurological symptoms/signs on examination or mobilisation.Spinal protection may be removed.
Patient who HAS acute neurological symptoms/signs on examination or mobilisation.Continue spinal protection and seek advice from an appropriate clinical team. 
Unconscious OR unable to Co-Operate with examination (see Notes)Spinal protection can be removed with caution providingConsultant Radiology report & No evidence of acute neurological deficitIt must be recognised there is a <1% chance of unrecognised injury. ANY evidence of neurological deterioration should be re-immobilised pending MRI
3Whilst there are no obvious features of spinal instability, the CT scan is either not of good quality and/or there are comorbidities confounding its interpretation.Continue spinal protection until MRI is performed and report available.

Magnetic Resonance Imaging is necessary when the following are present:

  • Suspected cord injury
  • Ambiguous CT scans, as per option 3 of standard 6
  • Inability to assess patient, as per option 2 standard 6 
  • Ankylosed spines with negative or indeterminate CT appearances for fracture
  • Contraindications to ionising radiation, for example in pregnancy

    Notes:

    • Option 1 Standard 6: Certain Spinal injuries may be combatable with removal of protection on agreement of the base speciality consultant:
      • Facet joint fractures of the thoracic and lumbar spine
      • Spinous process fractures
      • Wedge compression fracture with loss of vertebral body height of less than 25%
      • Type 1 odontoid fracture
      • End-plate fracture
      • Transverse process fracture
      • Trabecular bone injury
      • Osteophyte fracture, excluding corner or teardrop fractures
      • Isolated avulsion fractures
    • Option 2 Standard 6: Management of Unconscious or patients unable to fully co-operate with clinical exanimation is recognised as significant challenge. With advances in CT the number of significant injuries missed is very low <1%. However, there are significant risks associated with prolonged immobilisation, especially for frail patients who are more likely to fall into this group. 

    This pragmatic approach is in line with BOA-Standards, however, it must be recognised there is a chance of deterioration. If ANY evidence of neurological deficit the patient should be re-immobilised and reassessed for further imaging. 

    Complications of prolonged use of Immobilisation:

    • Impaired venous drainage and increased intracranial pressure
    • Difficult laryngoscopy and intubation
    • Increased risk of aspiration and ventilator-associated pneumonia
    • Difficult central venous cannula insertion
    • Increased risk of central venous cannula associated blood stream infections
    • Increased risk of pulmonary thromboembolism
    • Pressure necrosis leading to ulceration
    • Inability to provide good oral care
    • Failed enteral nutrition, gastrostasis and reflux
    • Restricted physiotherapy

    Reference:

    Hip Dislocation – Flowchart

    Dislocation of a Native Hip

    • Uncommon – High-Energy injury
    • All patients presenting with a suspected native hip dislocation following trauma (including falls from standing) must have a primary survey done to assess for other injuries.
    • Early Senior input (if not trauma team) and Resus
    • Neurovascular status of the affected limb must be assessed and documented. 

    Dislocation of Prosthetic Hip

    • Relatively common and frequently low energy
    • All patients should be assessed with low threshold to treat as trauma
      • Remember the biggest cause of ISS >15 Major Trauma in UK is older patients falling from standing height
    • Neurovascular status of the affected limb must be assessed and documented. 
    • If there is neurovascular compromise then move to Resus and inform ED senior 
    Read more

    Minimal and Moderate Paediatric Sedation

    The depth and type of sedation required in children depends on the procedure to be carried out. With the exception of procedures expected to cause pain most procedures in the Paediatric Emergency Department will not require pharmacological agents.

    Painful procedures preformed for children in the ED are usually done with Ketamine Sedation for which there is a separate pathway – Ketamine Sedation

     

    Minimal and Moderate Sedation

    Minimal – Drug induced calm, the patient is awake and responds to verbal commands but may have impairment of cognition and coordination.

    Moderate – Drug induced depression of consciousness but patients respond purposefully to verbal commands or tactile stimulation.

    Prior to consideration of drugs for painless procedures please consider consider alternative strategies. There are playspecialists at both sites between 8am and 8pm most days! If play therapists aren’t available consider the use of favourite songs, distraction toys, and of course the modern day all-in-one fix of a phone/tablet with the child’s favourite show!

    The help of an experienced nurse and capable parent cannot be underestimated. You should consider the use of intranasal fentanyl (see guideline) on presentation for more painful conditions, as well as paracetamol and ibuprofen.

    You might diminish the pain on infiltration of (warmed) local anaesthetics by injecting slowly and using a fine gauge needle. If oral sedation is to be considered oral Chloral Hydrate or Buccal Midazolam should be considered, neither of these require cannulation.

    Who can preform minimal/moderate sedation?

    • Senior medical staff (ST3+) with paediatric life support training
    • Must have done at least 6 months of anaesthetics/ICU
    • Familiar with giving medication of choice
    • Must have at least 2 staff members – someone to perform sedation, someone to monitor the patient
    • Department must be safe – Senior ED Clinician in charge (Consultant or Senior Registrar when Consultant not present in department has final say over if it is appropriate to perform at any given time

    Benzodiazepine and chloral both have very variable effects in children and careful consideration of an alternative plan should be made. Can imaging be delayed until a play-therapist is present? Could they be bought into PAU for their imaging requirements? Can a specialist attend to clean and suture a wound under ketamine instead of just cleaning the wound and dressing?

    Contraindications

    Any of the following comorbidities / contraindications require discussion with an anaesthetist / senior paediatrician:

    • Abnormal airway – including large tonsils or craniofacial anomalies e.g. receding jaw, stiff neck, restricted mouth opening, very large head
    • Raised intra cranial pressure or depressed conscious level
    • History of obstructive sleep apnoea
    • Major organ dysfunction including congenital cardiac anomalies
    • Moderate to severe gastro oesophageal reflux disease
    • Neuromuscular disorders
    • Bowel obstruction
    • Intercurrent respiratory tract infection
    • Known allergy to sedative drug / previous adverse reaction
    • Multiple trauma
    • Refusal by parent / guardian / child
    • Corrected age < 1 year because of severe prematurity
    • ASA 3 or more

    Fasting

    • For an emergency procedure in a child or young person who has not fasted, balance the risks and benefits of the decision to proceed with sedation before fasting criteria are achieved, on the urgency of the procedure and the target depth of sedation. Consider discussing this child with an anaesthetist.
    • Apply the 2-4-6 fasting rule for sedation in the ED unless child in significant distress and all other distraction and environmental alterations have been attempted.
      • 2 hours for clear fluids
      • 4 hours for breast milk
      • 6 hours for solids and formula milk

    Medications

    Chloral Hydrate

    Oral – give 45-60 minutes before procedure, it has an unpleasant taste but can be mixed with blackcurrant squash

    Dose: –

    Minimal Sedation: 30-50 mg/kg Maximum 1g

    Moderate Sedation: 100mg/kg Maximum 2g

    Side Effects

    Gastric irritation including nausea and vomiting reported.

    Beware cardiac arrhythmias and respiratory depression with loss of airway reflexes at high doses.

    There is NO reversal agent available

    Buccal Midazolam

    Buccal: Give 15 minutes pre-procedure and give half the dose into each side of the mouth

    Dose: –

    1-9 years:  0.2mg – 0.3mg/kg; Maximum 5mg

    10-18 years:  6mg – 7mg; Maximum 8mg if 70kg or over

    Side Effects

    Short acting benzodiazepine causing sedation, hypnosis, anxiolysis, anterograde amnesia

    Beware respiratory depression / hypotension / loss of airway reflexes at high doses.

    Can lead to a distressing paradoxical excitement in children

    Reversal agent: Flumazenil

    Flumazenil dose: 10 microgram/kg [Max 200 microgram], repeat at 1 minute intervals up to 5 times.

     

    Post sedation care

    • Observe for 1-2 hours until:
      • Conscious and responding appropriately
      • Able to walk unassisted (older children)
      • Vital signs are within normal limits
      • Respiratory status not compromised
      • Pain and discomfort addressed
    • Supervise child closely for 24 hours no driving for older children
    • Give advice leaflet to parents/carer
    • Ensure that sedation documented on EPR and drugs are signed for in CD book

    Full trust policy is available on intranet here

    Intranasal Fentanyl

    There is was a national shortage of Intranasal Diamorphine therefore many departments are now more comfortable using Intranasal Fentanyl as a replacement for rapid provision of opioid analgesia in children.

    1. Intranasal (IN) fentanyl is a safe, non-invasive and effective analgesic for children with moderate to severe pain
    2. Fentanyl should be used in combination with non-pharmacological and other pharmacological pain management
    3. It can be used in conjunction with nitrous oxide for procedural sedation or prior to procedural sedation with ketamine

    Dose is 1.5micrograms/Kg for the initial dose and 0.75micrograms/kg 10 minutes later if required.

    Drug Delivery

    Draw up the appropriate dose plus 0.1ml to allow for the dead space in the Mucosal Atomizer Device

    Attach the MAD to the syringe

    Sit the child at 45 degrees insert MAD loosely into the nostril and press the plunger

    Doses greater than 0.5ml should be split between 2 nostrils

     

    Contraindications

    • Blocked nose due to upper respiratory illness or epistaxis
    • Respiratory depression
    •  Hypovolaemia
    • Altered consciousness
    • Hypersensitivity to fentanyl
    •  Children below 1 year old

    Full Intranasal Fentanyl SOP

    Limping Child

    This is a relatively common  presentation within the ED that has a myriad of possible diagnoses ranging from sprain to malignancy. One thing to remember is that patients and relatives will look for a traumatic reason for limb pain, and may link it to minor injuries that would not have caused it.  Read more

    Knee (Cricket) splints

    Used for a several types of knee injury, the knee splint provides support and comfort to the knee joint, whilst allowing for the patient to weight bear as appropriate.

    The below indicative video demonstrates application of a leading brand.

    The process is very similar with other manufacturers, but the specific manufacturer’s instruction should be adhered to for the splint applied.

    Splints should be applied next to the skin, and certainly not over baggy clothing, as this may lead to movement of the splint, not providing the correct support.