Head, Neck & Back Injury

“Head, neck and back injuries are all seen in ED Minors and are often identified as patients for a Doctor to see. As with all Minors patients it is essential to be able to identify those that have a significant injury or are at risk of complications...”

CAP 3 – Acute Back Pain

CAP 18 – Head Injury

CAP 21 – Neck Pain

EM Curriculum: (click to view)

Head Injury

There are approximately 1 million presentations to hospital following a head injury in the UK each year, but many more are never assessed by a health professional (patient.info).

Head injury can be classified as (BMJ Best Practice)

  1. Mild (GCS 13-15; mortality 0.1%)

  2. Moderate (GCS 9-12; mortality 10%)

  3. Severe (GCS <9; mortality 40%)

85% of head injuries are classified as minor, however there are approximately 500,000 people in the UK living with disability as a direct result of a traumatic brain injury.

Back Pain

Back pain affects up to a third of the adult population of the UK. It is the second most common cause of long term absence from work in the UK after stress (European Back Pain Society Guidelines, 2004).

The vast majority of acute back pain is self limiting and of a "non-specific" character. However, approximately 3-5% of all back pain presentations represent serious pathologies including spinal cord compression and cauda equina syndrome (Bigos, 1994).

NICE and the European back society has produced several guidelines into the assessment and management of acute back pain including red and yellow flag symptoms. It is crucial to know these, as a missed diagnosis of cauda equina syndrome can lead to severe permanent disability. This level of disability is most commonly caused by delay in either diagnosis or referral to surgical teams.

C-Spine Injury

The prevalence of cervical spine injury following blunt trauma to the neck is 2.8% and of all those presenting, less than 1% will have suffered damage to the cervical spinal cord. However, the consequences following cord damage is devastating to both the patient and the family (College of Emergency Medicine Guidelines, 2010).

The immobilisation of the cervical spine is widely adopted throughout the UK however immobilisation itself can be a source of morbidity of neck pain in this patient group. It is currently a topic under much debate and a shift in practice may occur.

References:

Learning Outcomes from completing the tasks

  • Evaluate and manage acute back pain in the Emergency Department, and describe the important factors to consider.

  • Describe the assessment and management of head injury in the Emergency Department

  • Recognise and interpret the appearance of abnormalities on CT scan.

  • Explain when to immobilise a C-Spine.

  • Critique the complexities of managing head injury and neck injury in the context of major trauma.

Learning Outcome from face-to-face teaching

  • Identify and manage the patient with cauda equina syndrome in the Emergency Department.

  • Explain the management of the patient presenting with significant head injury.

  • Outline the options that are available to you and when to use them for emergency airway management in the trauma patient.

  • Assess and compose a management plan for neck trauma.

TASKS

Complete the following before the face to face session:

Task 1: Head Injuries

Duration: 45 mins

Life in the Fastlane provides an extensive resource on trauma and minor injury presentations to the Emergency Department. Some are more interactive than others, and you should be aware that this is an Australian site. However, the pages below provide you with a valuable insight into simple head injury cases, along with the physiology behind the management as well as a summary CT Head Interpretation. The Trauma: Traumatic Brain injury section gives you a chance to test your knowledge.

Task 2: A Pain in the Neck

Duration: 22 mins

Once again @Emcrit (Scott Weingart) provides an insightful podcast, in this episode he covers assessing and clearing c-spines. He mentions both Nexus and Canadian rules and suggests a strategy he applies.

As an extra task there is a follow up episode which covers some discussion which came up after his original entry.

Task 3: Lower Back Pain

Duration: 60 mins

This excellent RCEMLearning article is good for making you think about the acute presentations of back pain. It covers the simple all the way through to the emergency presentations, and provides useful tools to help you single out the serious pathologies. Click on the screenshot or link below to access the module.

#EM3 CONTENT

Lightning Learning:

MINI TEACHES:

EMERGENCY PROTOCOLS

You should familiarise yourself with relevant Local Guidelines, but for East Midlands Trainees we are aiming to host these on the website shortly (although this may password protected).

In the meantime please review your local guidelines relevant to head, neck and back pain.

CASE DISCUSSION

We have written a series of interactive cases (wikis) with short answer questions to be answered by trainees prior to the face to face teaching sessions. Currently this is only available to East Midlands Trainees.

Answer one or two questions before attending the face-to-face teaching session. Add comments to answers already given if you think it's appropriate. We will also provide tutor comments. If you find good resources that answer a question why not include links in your comment.

Part of the face-to-face teaching will be spent discussing the case(s) below:

“A male student has been brought in by ambulance on a Saturday night, he has been out drinking and got into a fight.”
“A 54 year old driver was involved in a rear shunt RTC at approx 40 mph.”

Additional Resources

Radiology Masterclass:

A page detailing the interpretation of c-spine radiographs. This is part of the axial skeleton module and if you have time it is worth going through the whole thing.

COURSE FEEDBACK

Once you have worked through the exercises, discussed the example cases and attended the face-to-face teaching, please complete the following form:

Updated: 4th January 2017