The Agitated Trauma Patient and the Lateral C-Spine
A 42-year-old restrained driver arrives in the emergency department after a rollover collision. He is alert but combative, confused, and repeatedly tries to sit up. His cervical spine is still in a rigid collar placed by EMS. The ordering provider wants a lateral cervical spine image to assess for injury before the collar is removed. You are working alone at 2 a.m.; there is no additional staff immediately available to assist with immobilization. The patient's oxygen saturation is 94% on room air and he has an IV line in his right antecubital fossa. He tells you he cannot lie flat because he feels like he is choking.
1. Before attempting the image, what patient-care and safety judgments must you make, and how do they change your plan?
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The patient cannot protect his own airway and is not reliably cooperative, so this is a situation where imaging must not proceed by simply forcing positioning. Key judgments:
- Airway and aspiration risk first. 'Feels like choking' plus confusion and borderline saturation means he should not be forced supine without monitoring. Notify the provider and nursing; request continuous pulse oximetry and suction available at the head of the table.
- Immobilization cannot be improvised by the technologist alone. Maintaining the collar and manual in-line stabilization requires trained hands. Call for help (nursing, provider, or security) rather than holding the patient yourself while operating the tube. Documenting that you attempted a lateral without stabilization would create an unacceptable risk of converting a stable injury to a cord injury.
- Combative behavior is a consent/cooperation issue. If the patient cannot cooperate, the study may need to be delayed until sedation or a trauma-team decision, or performed cross-table AP and lateral with the patient remaining in the collar and minimal movement.
- Line safety. Protect the IV from tension during any repositioning.
- Fall/table safety. Keep the stretcher locked, rails appropriate, and never leave him unattended.
The plan changes from 'shoot the lateral now' to 'stabilize, summon help, and image with in-line stabilization and cross-table technique only when it is safe.'
2. The provider insists you 'just get the film' and says the collar is enough. How do you respond, and what technique would you use if imaging proceeds?
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The collar limits motion but does not immobilize the spine; a lateral obtained while the patient twists or is unrestrained can misrepresent alignment. The appropriate response is to state the limitation clearly and request that a qualified person provide manual in-line stabilization or that the provider be present. This is a scope-of-practice and patient-safety boundary, not insubordination.
If the trauma team directs that imaging proceed:
- Keep the collar in place; do not remove it for positioning.
- Use a cross-table (dorsal decubitus) lateral with the cassette or detector vertical beside the neck and the beam horizontal, so the patient does not have to roll.
- Center to C4, collimate tightly, and use a 40-inch SID with a small focal spot.
- Because the patient is supine and the beam is horizontal, note that a grid or air-gap technique may be needed to control scatter.
- Shield the thyroid and breasts where they do not obscure anatomy.
- Include C1 through T1 if possible; if the shoulders obscure the lower cervical spine, a swimmer's view or repeat after stabilization may be needed.
Document the cooperation level, the stabilization used, and any limitation of the image.