01Approach to the Critical Patient/attcp37

Immediate priorities

›High-risk trauma context

›Manual in-line stabilization

›Rigid collar with neutral alignment

›If airway intervention, in-line stabilization maintained

›Airway risk

›If apnea or inadequate ventilation, RSI with in-line stabilization

›If difficult airway anticipated, early anesthesia or ENT support

›Breathing threats

›If hypoxia or respiratory fatigue with high cervical injury, early ventilation strategy

›If suspected diaphragmatic weakness, monitor for rapid decompensation

›Circulation threats

›If hypotension with bradycardia, neurogenic shock pattern

›If hypotension with tachycardia, hemorrhagic shock until proven otherwise

›Neurologic catastrophe triggers

›If progressive weakness or ascending sensory level, emergent spine consultation

›If priapism, consider neurogenic shock or high spinal cord injury

Monitoring and targets

›Physiologic targets

›Oxygen saturation 94% to 98%

›If chronic hypercapnia risk, individualized targets

›Systolic blood pressure 100 to 110 mmHg minimum in trauma

›If suspected spinal cord injury, MAP 85 to 90 mmHg target for 5 to 7 days in many spine protocols Class IIa

›Temperature normothermia

›If hypothermia, coagulopathy risk

Immobilization and movement

›Spine motion restriction

›Logroll only when necessary with team leader

02History/hx56

Mechanism and timeline

›Injury details

›High-energy blunt trauma

›MVC with rollover or ejection

›High-speed impact

›Diving or axial load

›Shallow water impact

›Fall

›Height and landing position

›Low-energy trauma with risk factors

›Ground-level fall with ankylosing spondylitis

›High fracture risk despite minor mechanism

›Time since injury

›Progressive symptoms since event

Symptoms and red flags

›Pain and neurologic symptoms

›Neck pain or midline tenderness

›Pain with movement

›Paresthesias in extremities

›Dermatomal pattern

›Weakness

›Upper extremity predominant pattern

›Gait instability

›New imbalance

›Bowel or bladder dysfunction

›Retention or incontinence

›Dyspnea

›Possible high cervical cord involvement

03Physical Exam/exam38

Primary survey spine focus

›Cervical spine precautions

›Midline tenderness

›Step-off or deformity

›Range of motion deferred until cleared

›If cleared clinically, active rotation only

Neurologic examination

›Neuro exam core elements

›Mental status

›GCS

›Motor strength by key myotomes

›C5 shoulder abduction

›C6 wrist extension

›C7 elbow extension

›C8 finger flexion

›T1 finger abduction

›Sensation by dermatomes

›Light touch and pinprick if feasible

›Reflexes and long-tract signs

›Hyperreflexia or clonus

›Hoffmann sign

›Perianal sensation and voluntary anal contraction when indicated

›Concern for cord injury

Vascular and associated injuries

›Associated injury screen

›Head and face trauma

›Basilar skull signs

›Chest trauma

04Differential Diagnosis/ddx29

Life-threatening and time-critical

›Catastrophic conditions

›Cervical spinal cord injury S14.0

›Neurogenic shock

›Epidural hematoma spinal

›Rapid neurologic decline

›Blunt cerebrovascular injury

›Vertebral artery dissection

›Atlanto-occipital dislocation

›High mortality risk

Cervical spine injury patterns

›Fracture and instability patterns

›Odontoid fracture S12.1

›Type II higher nonunion risk

›C1 fracture S12.0

›Jefferson burst

›Hangman fracture S12.11

›C2 pars fracture

›Subaxial cervical fracture S12.2 to S12.6

›Facet fracture or dislocation

›Ligamentous injury without fracture

›Instability risk

Mimics and alternate sources

›Non-spine causes

›Cervical strain or sprain

›No neurologic deficit

›Shoulder injury referred pain

›Clavicle fracture

05Laboratory Tests/lt21

Trauma baseline

›Baseline labs

›Complete blood count for bleeding concern

›Hemoglobin trend for occult hemorrhage

›Electrolytes and creatinine for contrast planning

›Potassium for arrhythmia risk

›Glucose mmol/L for altered mental status differential

›Hypoglycemia exclusion

›Coagulation studies if anticoagulant use or major trauma

›INR interpretation for reversal planning

›Type and screen if operative risk or major trauma

›Massive transfusion pathway triggers

Shock differentiation

›Perfusion and acid-base

›Venous lactate mmol/L

›Elevated lactate supports hypoperfusion

›Blood gas if ventilatory compromise

›PaCO2 mmHg for hypoventilation

Medication and intoxication context

›Selected tests when indicated

›Blood alcohol level for unreliable exam context

›Imaging favored when exam unreliable

›Pregnancy test in reproductive potential

›Imaging and medication planning

06Diagnostic Tests/dt64

Scoring Systems

›Clinical decision rules and classification

›Canadian C-spine Rule

›Sensitivity reported near 99% in validation studies

›Higher specificity than NEXUS in many comparisons

›NEXUS criteria

›High sensitivity reported in original multicenter study

›Reduced performance reported in some older adult cohorts

›NEXUS CT decision-making

›Persistent midline pain with negative CT not equal clearance in all patients

›Subaxial Injury Classification SLIC

›Morphology score

›Compression

›Burst

›Distraction

›Translation or rotation

›Disco-ligamentous complex integrity score

›Intact

›Indeterminate

›Disrupted

›Neurologic status score

›Intact

›Root injury

›Complete cord injury

›Incomplete cord injury

›Higher total score favors operative management

MRI

›MRI indications

07Disposition/dispo25

Level of care

›Admission and monitoring needs

›ICU criteria

›Any spinal cord injury

›MAP augmentation requirement

›Respiratory compromise or high cervical level involvement

›Need for ventilatory support

›Hemodynamic instability

›Vasopressor requirement

›Step-down or ward criteria

›Stable fracture with intact neurology

›Immobilization plan and pain control

Transfer and definitive care

›Transfer triggers

›Unstable fracture or dislocation

›No local spine coverage

›Suspected blunt cerebrovascular injury needing specialty input

›Antithrombotic planning

›Pediatric cervical fracture needing pediatric spine expertise

›Weight-based medication and imaging protocols

Discharge criteria

›Selected outpatient pathway

›Stable injury pattern with specialist plan

›Appropriate collar and instructions

›No neurologic deficit

›Reliable follow-up within 7 days

›Pain controlled on oral regimen

›Safe home supports

08Treatment/t63

Immobilization and stabilization

›Spine protection strategy

›Rigid cervical collar for suspected injury

›Proper sizing to avoid pressure injury

›Halo vest considerations

›Specialist-directed only

›Traction considerations

›Specialist-directed only

Hemodynamic management

›Shock management framework

›Hemorrhagic shock exclusion priority

›Balanced transfusion if indicated

›Neurogenic shock support

›Crystalloid bolus individualized

›Avoid fluid overload

›Vasopressor support for MAP targets

›Norepinephrine infusion

›Initiate 0.05 mcg/kg/min

›Titrate 0.02 to 0.05 mcg/kg/min every 2 to 5 minutes

›Phenylephrine infusion alternative

›Initiate 0.5 mcg/kg/min

›Titrate 0.5 mcg/kg/min every 5 to 10 minutes

›Vasopressin adjunct in refractory shock

›Fixed dose 0.03 units/min

›Avoid higher doses for ischemia risk

Airway and ventilation

›Airway strategy in suspected cervical injury

›RSI with manual in-line stabilization when needed

09Special Populations/sp23

Pregnancy

›Pregnancy considerations

›Maternal resuscitation priority

›Left lateral tilt if viable gestation

›Imaging risk framing

›CT when clinically indicated despite fetal radiation concerns

›Medication considerations

›NSAID avoidance in later pregnancy

›Opioids short-term when necessary with monitoring

Geriatric

›Older adult considerations

›Higher fracture risk with low-energy mechanisms

›Liberal CT imaging thresholds

›Degenerative changes complicate exam and imaging

›MRI consideration for persistent neurologic symptoms

›Odontoid fracture prevalence higher

›Nonunion risk counseling

Pediatrics

›Pediatric considerations

›Different injury patterns

›Higher ligamentous injury proportion

›Imaging strategy

›Radiation minimization balanced with miss risk

›MRI consideration when neurologic deficit with negative CT

›Weight-based medication dosing

›Opioid and sedative dosing per kg with monitoring

10Background/b27

Epidemiology

›Epidemiology facts

›Cervical spine injuries most often related to high-energy blunt trauma

›MVC and falls common mechanisms

›Spinal cord injury risk increases with fracture-dislocation patterns

›Facet dislocation high association

›Older adults have higher incidence with low-energy falls

›Osteoporosis contribution

Pathophysiology

›Injury mechanisms

›Flexion injury

›Anterior wedge compression

›Extension injury

›Central cord syndrome risk

›Axial load

›Burst fractures

›Rotation and translation

›Facet dislocation and instability

›Secondary injury cascade in cord injury

›Ischemia and inflammation

Therapeutic Considerations

›Treatment rationale

›Motion restriction prevents secondary displacement

›Collar fit and pressure injury prevention

›Early MAP optimization in spinal cord injury

›Perfusion support goal in many protocols Class IIa

›Early decompression and stabilization in selected patients

›Neurologic recovery association in some studies

11Patient Discharge Instructions/pdi20

Copy discharge instructions

›Discharge instructions for stable cervical spine injury pathway

›Collar use

›Continuous wear unless specialist-directed removal

›Skin checks twice daily for pressure injury

›Activity

›No contact sports

›No heavy lifting until cleared

›Pain control

›Acetaminophen as directed

›Avoid alcohol with opioids

›Follow-up

›Spine clinic or orthopedics within 7 days

›Imaging follow-up as directed

›Return to ED now

›New or worsening weakness

›New numbness or tingling

›Trouble breathing

›New bowel or bladder control problems

›Increasing neck pain not controlled with medication

›Fever or wound drainage if post-procedure

12References/r17

Clinical guidelines and evidence sources

›Core references

›Canadian C-spine Rule original derivation and validation studies

›High sensitivity for clinically important injury reported

›NEXUS criteria original multicenter validation study

›High sensitivity reported for low-risk clearance

›EAST practice management guidelines for cervical spine clearance in blunt trauma

›CT-based clearance pathways in many protocols

›ACS TQIP best practices in imaging for trauma

›Multidetector CT preference for cervical spine injury detection

›AANS CNS guidelines and position statements for acute spinal cord injury management

›Steroid use cautioned

›Classification tools

›SLIC subaxial cervical spine injury classification publications

›Operative decision support framework

›Blunt cerebrovascular injury

›BCVI screening criteria and management guidance in trauma literature

›CTA neck indications with cervical spine fracture patterns

Evidence & Review

Evidence & Review