Initial Spinal Management of Sedated and Ventilated Trauma Patients on Adult Critical Care

• Background and indications for standard operating procedure/protocol
• Procedure method (step by step)
• Algorithm

Background and indications for standard operating procedure/protocol

The above pathway has been modified from the established Portsmouth protocol (Richardson et al 2016).

This modification has been made following consultation with Consultant Neurosurgeons and Consultant Spinal Surgeons here at Leeds.

The areas modified includes

• establishment of exclusion criteria,
• timing of consultant radiology report and
• early institution of spine plan even in those whose clinical clearance is likely within 48 hours.

Following several serious untoward incidents locally involving patients with ankylosing spondylitis, these patients should be managed outside the protocol with direct consultant spinal surgeon involvement early and individually tailored spinal precautions to be instituted. This is because these patients often have a fixed flexion deformity in their spine and attempts to place collar, tape and lie them flat carries a significant risk of neurological deficit and risk to life (Thumbikat et al 2007). Furthermore, detection of fractures can be difficult in these patients and therefore MRI scans may need to be employed to exclude fractures (Leone et al 2016).

Motor/ sensory deficit prior to intubation should raise concerns of potential spinal cord injury associated with fractures. These patients should have CT and MRI scans urgently.

The reason for urgent MRI scan is to detect if there is a surgical lesion compressing the cord or cauda equina which would need to be dealt with as an emergency. Again the care of this group of patients should be tailored to individual patients with early involvement of consultant surgeon and therefore should be managed outside this protocol.

Finally, the sensitivity of CT to detect fracture diminishes with increasing slice thickness (Panczykowski et al 2001).

Certainly, scans done at Leeds Teaching NHS Trust will be less than 3mm. However, caution needs to exercised with regards to patients transferred from elsewhere within the catchment population of the Leeds Spine Service also those repatriated from abroad.

Timing of consultant radiology report

Apart from exclusion criteria, at Leeds, consultant radiology report is not available immediately due to local on-call arrangements. Therefore, the protocol cannot be instituted immediately once patient arrives in ICU.

Following consultation with radiology, we have received assurances that a consultant report should be available by 6pm during day-time imaging (8-5pm).

Out-of-hours imaging on the other will be available by mid-day the following day. Therefore, the spine plan should be employed for all patients around these two time points.

Early spine clearance

Finally, even if clinical clearance is likely within 48 hours, the consultant spinal surgeons would still employ the necessary spine plan based on CT report by a consultant radiologist and would not wait 48 hours for a clinical assessment. This is based on publications that have highlighted in the absence of fracture and malalignment on CT, patients will not have clinically significant instability that would need surgical fixation (Patel et al 2015, Hogan et al 2005).

This approach would allow early collar removal and complications associated with employing prolonged spine precautions (pressure sores, aspiration pneumonia, infection control etc) (Ackland et al 2005, Harrison et al 2008).

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Procedure method (step by step)

Exclusion criteria

• Patients with ankylosing spondylitis,
• Patients with motor/ sensory deficit (prior to sedation)
• CT slice thickness ≥ 3mm

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Algorithm

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