NCEPOD: Trauma - Who Cares? - London Health Programmes

CHAPTER 6 - Airway and breathingTable 58 shows reasons for advisors’ concerns.Table 58. Reasons for advisors’ concerns withregard to inappropriate control of cervical spineNo evidence of protection 22Delay in protection 5Not appropriately cleared 11Needed imaging 3Unable to fi t collar 4Other 10Total 55Imaging and clearance of the cervical spine was oftencommented on during the peer review process. There werefrequent problems with adequate imaging of the cervical spinein unconscious patients. There were often multiple attemptsat plain x-rays of the cervical spine, even in those patientswho were undergoing CT scanning of another body part.Reluctance to provide CT imaging of the cervical spine at thesame time as head CT scan was commonly encountered.Case study 1A young patient was admitted following a motorvehicle crash. Initial Glasgow Coma Score was 5 andthe right pupil was fi xed and dilated. The patient wastransferred for a CT head scan which showed somecerebral contusions and swelling but no lesion requiringneurosurgical intervention. Given the mechanism ofinjury there was concern that the cervical spine may alsohave been damaged. No CT of the cervical spine wasperformed; instead the patient was transferred back tothe emergency department to have plain x-rays of thecervical spine. Despite several attempts, plain x-raysprovided inadequate views of the whole cervical spineand the patient was then transferred back to the CTscanner for CT imaging of the cervical spine.The clinical scenario in Case study 1 was not uncommon.Key findingsOne in eight patients arrived at hospital with eithera partially or completely obstructed airway.Prehospital intubation failed on 11/85 attempts (12.9%).131 patients were intubated either on admission orwithin the fi rst 30 minutes after admission to hospital.Data on grade of medical staff performing trachealintubation was poorly documented and not available in223/362 cases (61.6%).Management of the airway was consideredunsatisfactory in 52/741 cases (7%).The management of the potentially unstable spine wasconsidered unsatisfactory in 55/660 cases (8.3%).RecommendationsThe current structure of prehospital management isinsuffi cient to meet the needs of the severely injuredpatient. There is a high incidence of failed intubationand a high incidence of patients arriving at hospital witha partially or completely obstructed airway. Changeis urgently required to provide a system that reliablyprovides a clear airway with good oxygenation andcontrol of ventilation. This may be through the provisionof personnel with the ability to provide anaesthesiaand intubation in the prehospital phase or the use ofalternative airway devices. (Ambulance trusts)CT scanning of the cervical spine should be performedin adult patients who have any of the following features:• GCS below 13 on initial assessment• has been intubated• is being scanned for multi-region trauma(Radiology heads)68