D. Scantling1, E. Gleeson1, J. Fazendin1, A. Galvez1, A. Teichman1, J. Eakins2, B. McCracken1 1Drexel University/Hahnemann University Hospital,Surgery,Philadelphia, PA, USA 2AtlantiCare Regional Medical Center,Trauma Surgery,Atlantic City, NJ, USA
Introduction:
Cervical spinal cord injuries (CSCI) often necessitate ventilator dependence. Although endotracheal tubes are the initial airway access of choice, they convey substantial morbidity and tracheostomy is recommended if ventilator support is anticipated to be 7 days. Identifying patients who will need this duration of support and performing early tracheostomy could prevent substantial morbidity, hospital costs and even survival. Prior attempts to identify these patients have been lacking and this provides little data to discuss with consenting family.
Methods:
A retrospective review of the Pennsylvania Trauma Outcome Study (PTOS) database was performed identifying patients with both a cervical spine fracture and CSCI from 2005-2014. 2,339 patients initially met this description. Patients were excluded for incomplete data, never requiring any ventilator support or death within 6 days. Patients with C1-4 CSCI were included. 223 patients met these metrics. Cohorts were created based on type of CSCI and those needing ventilator support for ≥7 days. ISS, AIS, age, GCS, LOS, ICU LOS, mortality, tracheostomy were evaluated. Analysis was accomplished using confidence intervals, Mann-Whitney U tests and Chi Square.
Results:
Of 223 patients meeting inclusion criteria, 142 had complete C1-C4 CSCI.133/142 required ≥7 ventilator days (93.7%, 95% CI 88.3% to 97.1%) and 120/142 underwent tracheostomy (84.5%, 95% CI 77.5% to 90%). Of those with ≥7 ventilator days, mean highest level of fracture was 3.35, ISS was 55.8, mean ventilator days were 30.54, GCS was 7.60 and GCS motor was 2.59. 20 died and 119 had a surgical airway placed (89.5%, 95% CI 83.0% to 94.1%). Of those with ≤6 ventilator days, mean highest associated fracture level was 4.67, ISS was 35.11, age was 46.33, mean ventilator days was 2.11 (range 1-4). Mean GCS was 14.25 and all patients had a motor score of 6. One underwent tracheostomy. Significant differences were identified between groups for highest level of fracture, ISS, GCS and GCS motor score (p=0.012, p=0.030, p=0.0001, p=0.0001). AIS head, face and neck were not significant (p=0.803, p=0.412 and p=0.624). Compared to previously published data, our methodology identified significantly more patients receiving tracheostomy (84.5% vs 64.2%, p=0.007).
Conclusion:
This data should be used to guide family discussions to promote very early tracheostomy for patients with complete C1-C4 injuries associated with a cervical spine fracture, require any ventilator support and are expected to survive for a week. We anticipate decreases in morbidity, length of stay and hospitalization costs amongst these patients.
