• 
• 

Three Part Question

In [a patient with an isolated gunshot wound to the cranial vault] is [the risk of cervical spine injury so low] that [c-spine precautions may be discarded]

Clinical Scenario

A 16 year old male is brought to the emergency department following a drive by shooting. He has an isolated entry wound to the right temporal region consistent with a .22 calibre bullet. On arrival he is cardiovascularly stable but has GCS of 5 (extending to pain) with reactive pupils. You decide to intubate using an RSI technique but you are worried as the patient has a small mandible and may present difficulties in intubation. You wonder if it is safe to remove the C-spine collar, flex the neck and extend the head, but you are worried about a c-spine injury. You take a risk, remove the collar and intubate the patient. Later you wonder just how risky it was.

Search Strategy

MEDLINE OVID 1966-May 2000
[exp head injuries/ or "head injury".mp OR exp. craniocerebral trauma OR cranium.mp] AND [exp. Wounds, gunshot/ OR wounds penetrating/ OR exp wounds, stab/ OR "penetrating trauma".mp.] AND [exp cervical vertebrae/ OR exp spinal cord injuries/ OR exp spinal injuries/] LIMIT to human, English and abstracts

Search Outcome

30 papers of which 3 were relevant to the original question.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Kennedy FR, et al. 1994. USA.	266 patients with gunshot wounds to the head.	Observational retrospective chart review.	Spinal injury associated with gunshot wound to head	5/266 (2%) of patients had a concomitant spinal injury	Retrospective review. Of 308 eligible consecutive patients only 266 had notes available for review and 109 did not have xrays performedGold standard was a lateral x-ray of the neck. Despite the 0% event rate in wounds limited to the calvaria, the confidence interval is still quite high.
			Spinal injury for gunshot wounds limited to the Calvaria	0/105 (0%) had spinal injury
Kaups KL and Davis JW. 1998. USA.	215 patients with gunshot wounds to the head. DOA patients and patients with wounds to the neck were excluded. Gold standard = clinical exam/radiology/CT/autopsy.	Observational retrospective chart review.	Patients with cervical spine injury.	3/215 (1.4%).	Missing data on 7% of eligible patients.
			Ability to predict c-spine injury.	All cervical spine injuries were predicted from bullet trajectory on clinical examination. NO "unexpected" c-spine injuries in patients with wounds limited to the cranial vault.
Chong CL, Ware DN, Harris JH Jr. 1998. USA.	53 patients presenting at a level 1 trauma center with a gunshot wound to the head. Wounds to the face and neck excluded. Gold standard = plain film +/- CT in 6% for equivocal findings.	Observational retrospective chart review.	Patients with c-spine injury.	No patients had cervical spine injury.	Small sample studied.

Comment(s)

Patients who have been shot in the head are likely to have raised intracranial pressure. Consequently early removal of the cervical collar may be beneficial as this has been shown to reduce ICP. The risk of removing the collar must be balanced against that of increasing intracranial pressure. The study by Kennedy is flawed as there are a large number of patients excluded from the analysis due to missing data. However, the studies do suggest that if the wound is limited to the vault of the skull (calvaria) and the clinical assessment of the track of the bullet does not suggest a c-spine injury then c-spine precautions may be unnecessary. Indirect cervical spine injury is not seen in these studies.

Clinical Bottom Line

In patients with an isolated gunshot wound to the vault of the skull, and where the track of the bullet wound does not clinically suggest a c-spine injury, c-spine precautions are not required.

References

1. Kennedy FR, Gonzalez P, Beitler A, Sterling-Scott R, Fleming AW. Incidence of cervical spine injury in patients with gunshot wounds to the head. Southern Medical Journal 1994;87(6):621-3.
2. Kaups KL and Davis JW. Patients with gunshot wounds to the head do not require cervical spine immobilization and evaluation. Journal of Trauma-Injury Infection & Critical Care 1998;44(5):865-7
3. Chong CL. Ware DN. Harris JH Jr. Is cervical spine imaging indicated in gunshot wounds to the cranium? Journal of Trauma-Injury Infection & Critical Care. 1998;44(3):501-2