still confused over removing C collar

[RevEM]

Hey gang,
I'm confused over something and want to see how you guys do it at your places. This was not my case, but i was outside looking in.
30ish yo intoxicated M found down. Head and C spine CT negative. He was ready to go to the detox unit here in town, but someone (again I was not involved directly so I don't know who) said the c collar needed to stay on. At my shop if they have continued midline pain then they get f/u and go out in a soft collar with precautions. "They" argued he could not say if he had continued pain as he was still very drunk so he gets a soft collar. I have seen MANY people CTed and shipped to detox with no soft collar so I was a bit confused. I see the point of keeping a soft collar on, but i had never seen it done.
what's your practice?
thanks,
rev

---

Members don't see this ad.

 

[Apollyon]

"Soft collar" is junk and useless - do you mean the "Miami J", which is padded, but has a rigid frame (blue padding and white frame)?

And was the guy still drunk? Another option is "flexion-extension" views.

 

[RevEM]

"Soft collar" is junk and useless - do you mean the "Miami J", which is padded, but has a rigid frame (blue padding and white frame)?

And was the guy still drunk? Another option is "flexion-extension" views.

I think we technically use the ASPEN, but from my understanding it is the same thing as the Miami J.

Yes, the guy was still waaaay drunk. Now can't flexion/extension be dangerous? especially in a basically unresponsive guy? or is that the next best step?

thanks

 

[Hamhock]

Hey gang,
I'm confused over something and want to see how you guys do it at your places. This was not my case, but i was outside looking in.
30ish yo intoxicated M found down. Head and C spine CT negative. He was ready to go to the detox unit here in town, but someone (again I was not involved directly so I don't know who) said the c collar needed to stay on. At my shop if they have continued midline pain then they get f/u and go out in a soft collar with precautions. "They" argued he could not say if he had continued pain as he was still very drunk so he gets a soft collar. I have seen MANY people CTed and shipped to detox with no soft collar so I was a bit confused. I see the point of keeping a soft collar on, but i had never seen it done.
what's your practice?
thanks,
rev

I agree with apollyon: soft collar is junk.

However, I also think that mgt of C-spine is junk; or, at least dogma.

Sadly, given how rare true injury is, I doubt we will ever have good EBM.

In our department, some folks remove the collar after a negative CT regardless of exam or mental status or NEXUS; others await NEXUS criteria; others say without neuro deficit or paresthesias, midline tenderness means nothing if CT neg; others keep the collar (usually Miami J, even if discharged) until MRI.

I find the publications regarding neg CT and no clinically significant injuries from ?OH or ?Illinois comforting, if not convincing...but I think a lot of that is just based on how rare true C/S injury is.

Until we suck it up, pay for, and design a huge, multi-center study with the gold standard (MRI and exam), we will never know.

HH

 

[The White Coat Investor]

I agree with appolyn: soft collar is junk.

However, I also think that mgt of C-spine is junk; or, at least dogma.

Sadly, given how rare true injury is, I doubt we will ever have good EBM.

In our department, some folks remove the collar after a negative CT regardless of exam or mental status or NEXUS; others await NEXUS criteria; others say without neuro deficit or paresthesias, midline tenderness means nothing if CT neg; others keep the collar (usually Miami J, even if discharged) until MRI.

I find the publications regarding neg CT and no clinically significant injuries from ?OH or ?Illinois comforting, if not convincing...but I think a lot of that is just based on how rare true C/S injury is.

Until we suck it up, pay for, and design a huge, multi-center study with the gold standard (MRI and exam), we will never know.

HH

Agree. How often does someone have a significant ligamentous injury without any sign of injury (fracture or otherwise) on CT but will dramatically worsen by removing the C-collar?

As a general rule, if they have a negative CT and aren't being shipped to a trauma center with other injuries, I take the collar off. Of course, most of these guys have normal mental status, which makes the whole process much less risky.

I can't believe we worry about this issue and yet consider plain films to ever be adequate to rule out c-spine injury.

 

[SoCuteMD]

.

 

[WilcoWorld]

I seem to be in the minority on this at my trauma center, but if there is a negative CT and the patient has a normal neuro exam - the collar comes off. I don't care about persistent pain or being a bit drunk, but you have to be with it enough to participate meaningfully in a neuro exam.

 

[xaelia]

So a single cross-table lateral isn't good enough for screening anymore?

 

[tkim]

So a single cross-table lateral isn't good enough for screening anymore?

C-spine XR is for show only and 'therapeutic' radiation. If you believed there was a true C-spine injury, you'd skip the XR and go straight to CT.

 

[CestaVie]

if all imaging negative and pt still tender, i give them the soft collar... and out you go.

 

[xaelia]

If a patient has negative CT imaging and, for some reason or another, you're concerned about unstable ligamentous injury, flexion/extension views have inadequate sensitivity. But, regardless, the couple studies demonstrating all the CT-negative c-spine injuries come out of the SICU, which is not the population we're sending home from the ER - so I think it's reasonable not to worry as much about it.

In the initial scenario, the drunk patient in a c-collar stays in his collar (in theory) after a negative CT until he can demonstrate normal neurologic function on active rotation and flexion of the head. If he fails, he gets an MRI. I don't do more imaging on people with isolated pain. Soft collars can be purchased by the patient at a drugstore to garner more sympathy if they so desire.

 

[RevEM]

Wow
so there is a lot of variability. maybe that is why I am so confused.
It is pretty amazing how many drunks I have seen sent to detox after a neg CT and still very drunk yet no collar. interesting.
thanks for the insight!
rev

 

[CestaVie]

Wow
so there is a lot of variability. maybe that is why I am so confused.
It is pretty amazing how many drunks I have seen sent to detox after a neg CT and still very drunk yet no collar. interesting.
thanks for the insight!
rev

yup it's all about the attending. Some attendings are so damn clueless it's pathetic... all I hear is "consult ____." I would say, why? What can they do that would actually HELP that person except having them sit around in the floor for "obs." And the response is generally, "they're too unstable." So basically we have no idea how the consulting service will actually help the patient but we should just consult them anyway. Ridiculous. Sorry if I sound angry.

 

[NinerNiner999]

NEXUS is still the "best" study and set of guidelines to date, but still not perfect. Also, there is no clear definition of "impairment" in the criteria, which still leaves a fair amount of discretion to the emergency physician to determine whether a patient is "clinically" able to meet the criteria for clearance. That being said, I typically leave the collar on drunks until they are "sober" clinically to give a reliable exam.

In regards to CT C-spine: This is by no means a "gold standard test" and it could be argued that subtle transverse fractures of the spine could be missed on sectioning by the scanner. They will not show up on "scout" or recon views either because these are calculated based on the sections. A "purist" might argue that the "best" imaging of the cervical spine might be a combination of a CT and plain film series, but this would be getting very argumentative and clearly not feasible for everyday practice...

 

[Apollyon]

A "purist" might argue that the "best" imaging of the cervical spine might be a combination of a CT and plain film series, but this would be getting very argumentative and clearly not feasible for everyday practice...

Best imaging for the c-spine is MRI - bar none; ask any radiologist. However, that is right in the crosshairs of "clearly not feasible for everyday practice" by any means at all.

 

[Rendar5]

Not sure why you'd send someone drunk to detox though...seems to me that you might need to know whether or not they'd want detox, not something a drunk guy can accurately tell ya. Hell, they might just wanna go grab a beer instead.

 

[Arcan57]

Drunk trauma patients stick around until sober enough to get an accurate exam. The potential for missed injury (of any type) is too high. Putting someone in a Miami-J for 2 weeks has it's own sort of morbidity, and I wouldn't send someone home in one that had a negative CT-scan and no neuro deficits. If they have parasthesias, then I'm MRI'ing them.

 

[KYTNOH]

An interesting study would be to see what the compliance rate is for patients discharged with 10-14 days of C-collar followed by a flex-ex. I have no illusions that 3/4 of the patients I send out with a collar will take it off once they get home. Of course, when I dictate that they were instructed to wear their collar for two week and then get repeat imaging that takes the responsibility off of me for the most part.

 

[xaelia]

Of course, when I dictate that they were instructed to wear their collar for two week and then get repeat imaging that takes the responsibility off of me for the most part.

"So, doctor, you were concerned enough about an unstable ligamentous cervical spine injury that you placed them in a hard cervical collar? Does anyone in the jury think it should be the expectation of a reasonable physician to expect an individual to wear such a restricting device 24 hours a day without interruption for two weeks?"

The collar-and-home and flex-ex views are relics of a different practice environment - which isn't to say that sort of environment doesn't still exist in community and critical access hospitals - but I would have a hard time saying it is defensible practice if MRI were available.

 

[KYTNOH]

"So, doctor, you were concerned enough about an unstable ligamentous cervical spine injury that you placed them in a hard cervical collar? Does anyone in the jury think it should be the expectation of a reasonable physician to expect an individual to wear such a restricting device 24 hours a day without interruption for two weeks?"

Absolutely. We send people home in much more restrictive devices. At this point it is neither cost effective nor an appropriate use of resources to MRI everyone with a little neck pain after an MVC. Of course, if there is a high clinical suspicion of ligamentous injury then an MRI would be appropriate, but for the low-risk patient C-collar would be the more appropriate dispo (although I think there's an argument to be made that C-collar is unnecessary in the low risk patient).

My approach to traumatic neck pain:
1. No pain on exam, no neuro deficit, no intoxication, no distracting injury (NEXUS criteria) then no scan and no collar.
2. If they do not meet NEXUS criteria then CT C-spine.
3. CT C-spine negative with resolved pain or simply soreness and no neuro deficit, then collar off.
4. CT C-spine negative with neuro deficit, then MRI
5. CT C-spine negative with suspicious pain on exam but no neuro deficits, then C-collar with follow up.

 

[jethro136]

Absolutely. We send people home in much more restrictive devices. At this point it is neither cost effective nor an appropriate use of resources to MRI everyone with a little neck pain after an MVC. Of course, if there is a high clinical suspicion of ligamentous injury then an MRI would be appropriate, but for the low-risk patient C-collar would be the more appropriate dispo (although I think there's an argument to be made that C-collar is unnecessary in the low risk patient).

My approach to traumatic neck pain:
1. No pain on exam, no neuro deficit, no intoxication, no distracting injury (NEXUS criteria) then no scan and no collar.
2. If they do not meet NEXUS criteria then CT C-spine.
3. CT C-spine negative with resolved pain or simply soreness and no neuro deficit, then collar off.
4. CT C-spine negative with neuro deficit, then MRI
5. CT C-spine negative with suspicious pain on exam but no neuro deficits, then C-collar with follow up.

I think it's interesting that no one has really mentioned clinical judgement or mechanism in this discussion. I think we've all seen the pts with a minor rear-end collision with hysteria and pan-spinal tenderness. These patients aren't clearable by NEXUS, but no reasonable physician would believe that a 10-15 mph rear-end collision could possibly create an unstable ligamentous injury in a young healthy person. So in the scenarios above my practice is:

1) of course - no films
2) imaging modality depends on mechanism, as I mentioned above. If I'm actually concerned about an injury I usually CT, but if it's just the "not technically clearable but ludicrous mechanism" then I plain film
3) this is sort of a bummer scenario because it seems like a pt who is clearable without the CT you got. When I have a found down drunk without massive head trauma that is going to have to stay in the dept to sober up, I will just get plain films and repeat exam when clinically sober. Admittedly, this is more possible because I work in an academic center where observation and handoffs are more acceptable.
4) of course. Plus NSGY consult.
5) This one again depends on mechanism. Unrestrained rollover MVA with neg CT but persistent midline pain = collar and follow-up. Ground level fall with negative imaging and normal exam usually but persistent tenderness = no collar, motrin, and GTFO.

 

[leviathan]

These patients aren't clearable by NEXUS, but no reasonable physician would believe that a 10-15 mph rear-end collision could possibly create an unstable ligamentous injury in a young healthy person.

Canadian C-Spine rule can still clear them.
http://www.ohri.ca/emerg/cdr/docs/cdr_cspine_poster.pdf

 

[shoal]

Jethro:

As for point #5. I've seen a pt fall out of bed with atlas fractures although easily visualized on CT scan. I'm not quite sure mechanism of trauma always plays a role. Clinical judgement really needs to come into play.

Although still an aspiring EM physician, I think most realize guidelines and scales including nexus, Canadian head ct rules, NIH stroke scale, ABCD2 etc are just that guidelines to help assess pts with our professional judgement.

 

[deuist]

At my institution, the trauma team won't remove a collar even with a negative CT. Last night, some one asked me to get a flexion-extension x-ray on someone who already had a negative CT of the C-spine because she "still had neck pain." ?!?!

 

[Rendar5]

At my institution, the trauma team won't remove a collar even with a negative CT. Last night, some one asked me to get a flexion-extension x-ray on someone who already had a negative CT of the C-spine because she "still had neck pain." ?!?!

well to be fair, i think they see the difference between those 2 as something akin to a stress test v. a EKG. function testing can sometimes reveal an issue. although i'm not sure i believe in doing that routinely in ED practice.

 

[leviathan]

At my institution, the trauma team won't remove a collar even with a negative CT. Last night, some one asked me to get a flexion-extension x-ray on someone who already had a negative CT of the C-spine because she "still had neck pain." ?!?!

The trauma surgeons do that here all the time. It's a way to assess for ligamentous injury I guess.

 

[jethro136]

Jethro:

As for point #5. I've seen a pt fall out of bed with atlas fractures although easily visualized on CT scan. I'm not quite sure mechanism of trauma always plays a role. Clinical judgement really needs to come into play.

Although still an aspiring EM physician, I think most realize guidelines and scales including nexus, Canadian head ct rules, NIH stroke scale, ABCD2 etc are just that guidelines to help assess pts with our professional judgement.

Not quite sure what to say about your patient. Did you get plain films? My point with #5 was that if you have imaging (whether plain films or CT) that are negative for fracture, and your suspicion for ligamentous injury is low (i.e. low energy mechanism such as falling out of bed) then I don't discharge in a collar. The collar is only if you think there's a chance they disrupted both the ALL and PLL. I think we've all seen someone who has a surprising fracture - that's why we get films. For example, I tend to ignore NEXUS and image people who have axial loading mechanisms because I don't think I can push on the dens very effectively to assess for pain. My overall point was essentially the same as yours - guidelines are good, guidelines plus rational clinical judgement is better.