Which of the following is the most appropriate next step in management for this patient’s condition?
This patient presents to the Emergency Department after a high-speed motor vehicle accident in the setting of alcohol intoxication. On examination, he is intoxicated with a GCS of 14 (normal GCS is 15). The first step in evaluating any trauma patient involves the primary survey. The primary survey is also known as the “ABCDEFs” of trauma. This stands for Airway, Breathing, Circulation, Disability, Exposure, and FAST exam (Focused Assessment with Sonography in Trauma). Each letter should be assessed in alphabetical order to avoid missing a time sensitive life-threatening condition. The primary survey should be conducted prior to taking a full history.
After the primary survey, a more detailed physical exam (secondary survey) is conducted, followed by interventions and a focused patient history. This patient is intoxicated but is awake with a patent airway. Endotracheal intubation (Choice C) is not indicated. Neurosurgical consultation (Choice D) is also not indicated at this stage as there is no concrete information to indicate a surgical emergency. CT imaging may demonstrate a cervical spine fracture or intracerebral bleeding, but these results are not provided by the question stem. A CT scan of the head without contrast (Choice B) is a reasonable test for this patient given his significant mechanism of injury and intoxication on exam. However, both a CT scan of the head and cervical spine (Choice A) should be ordered due to the patient’s intoxication creating an unreliable physical exam. Alcohol intoxication or drug use can alter a patient’s ability to sense pain and provide accurate information. The presence of intoxication should always raise awareness for possible occult injuries.
Of note, intoxication and altered mental status are indications to perform a CT scan of the cervical spine based on a well-validated decision-making tool known as the NEXUS criteria (National Emergency X-Radiography Utilization Study). Other criteria on the NEXUS tool that support CT cervical spine imaging are midline spinal tenderness, the presence of a focal neurologic deficit, or the presence of a distracting injury (i.e., femur fracture). The Canadian C-Spine Rule and Canadian CT Head Rule are other validated decision-making tools to help a clinician decide on whether or not to order CT head or cervical spine imaging. Correct Answer: A
- MDCalc. (2020). Calculated decision support for emergency medicine practice subscribers. https://www.ebmedicine.net/media_library/files/Trauma-Imaging-Resuscitation-CD.pdf
- Lalani, N. (2013). My approach to clearing C-spines. Canadiem. https://canadiem.org/clearing-the-c-spine/