Should C-Spines Be Cleared in the Prehospital Setting? Brian Walsh, MD, MBA Emergency Medical Associates Morristown Memorial Hospital Morristown, NJ, USA

Where do we stand? Should c-spines be cleared prehospitally? Should all “trauma” patients have C-spine immobilization? Do patients who arrive in ED with c-collars get bigger work-ups / stay longer? Should everyone who arrives in ED with c-collar have imaging?

Case 1 30 y.o. male fell from roof, landing on feet and then back. No head trauma, no neck pain Awake and alert. Air-medical transport to trauma center.

Case 2 75 y.o. tripped down 1 step, striking head. No LOC. No headache or neck pain / tenderness. Small contusion over right eye, open toe fracture

Case 3 4 y.o. boy found at bottom of swimming pool Unconscious, no evidence of trauma.

Case 4 35 y.o. in head-on collision at 15 mph. No intrusion into vehicle. Awake and alert. Complains of sore wrists. No headache or neck pain or other complaints. No neck tenderness.

ED Literature

Nexus Criteria Low Risk No posterior midline cervical tenderness No evidence of intoxication Normal level of alertness No focal neurologic deficit No painful distracting injuries

Distracting Injuries Any condition thought by the clinician to be producing pain sufficient to distract the patient from a second (neck) injury. Examples include (not limited to): any long bone fracture; visceral injury requiring surgical consultation; a large laceration, degloving injury, or crush injury; large burns; or any injury producing acute functional impairment.

Canadian C-spine Criteria High Risk: Age > 65, parasthesias, or dangerous mechanism a fall from an elevation of >=3 feet or 5 stairs; an axial load to the head (e.g., diving); a motor vehicle collision at high speed (>100 km per hour) or with rollover or ejection; a collision involving a motorized recreational vehicle; a bicycle collision.

Canadian C-spine Criteria Low Risk Simple rear-end collision, or Sitting in the ED Ambulatory at any time Delayed onset of neck pain Absence of midline tenderness

Canadian C-spine Criteria High Risk  Radiograph Low Risk and able to rotate neck  Do not need films

Nexus vs. Canadian Prospecitive study of 8283 patients ~10% did not have ROM evaluated Nexus: sensitivity 90.7; Specificity 36.8 Canadian: sensitivity 99.4; Specificity 45.1 CCR missed 1, NLC missed 16 CCR use would result in fewer x-rays (56% vs 67%) Stiell IG, et al. N Engl J Med. 2003.

Prehospital Clearance

Prehospital Immobilization Is it even necessary? 5 year retrospective study 2 University hospitals – 1 immobilized, 1 did not. Immobilized patients MORE likely to have neurological injuries (OR 2.0, <2% chance immobilization helps.) Similar results if limited to C-spine fractures Hauswald. Academic Emergency Medicine. 1998

Prehospital Clearance - Survey Survey of 300 ED Medical Directors: 42% think all trauma patients should be immobilized 12% of hospitals: C-spine films are obtained on all immobilized patients. Cone, et al. Current practice in clinical cervical spinal clearance: implication for EMS. Prehospital Emergency Care. 1999

Protocol Implement spinal immobilization in the following circumstances: 1. Spinal pain or tenderness, including any neck pain with a history of trauma. 2. Significant multiple system trauma. 3. Severe head or facial trauma. 4. Numbness or weakness in any extremity after trauma. 5. Loss of consciousness caused by trauma. 6. If altered mental status (including drugs, alcohol, and trauma) and: • no history available; • found in setting of possible trauma (eg, lying at the bottom of stairs or in the street); or • near drowning with a history or probability of diving.

Prehospital Clearance – Standardized Patients Prospective, randomized “standardized patient” encounters – EP vs. medics 5 patients, 10 EP-medic pairs The kappa statistic for the immobilization decision was 0.90. Only one case differed; the paramedic immobilized, the physician did not. Sahni, et al. Paramedic evaluation of clinical indicators of cervical spinal injury. Prehosp Emerg Care. 1997.

Prehospital Clearance – Air-Medical 329 Patients, 49 spinal injuries, 12 unstable. 40 met criteria for no immobilization 4 had fractures 90% sensitivity, 16% specificity “Prehospital algorithms during air-medical transport are not useful.” Werman, Journal of Trauma. 2008.

Prehosptial Clearance - Submersion 20 year retrospective study, 2,244 patients 11 (0.5%) had C-spine injuries All of them had Clinical signs of serious injury, AND History of diving, MVC, or fall from a height Watson, Journal of Trauma. 2001.

Prehospital Clearance EMTs cleared 67% of 103 trauma patients of C-spines at scene following algorithm with no known bad outcomes Nexus criteria Armstrong, et al. Prehospital clearance of the cervical spine. Emergency Medicine Journal 2007;24:501-503

Prehospital Clearance Retrospective review after implementation of protocol 396 patients Medics complied with standing orders for C-spine immobilization 92%-96% of time No missed fractures EMS Adherence to Prehospital C-spine Clearance Protocol. California Journal of EM. 2001.

Prehospital Clearance 2,220 patients with data collection form 59% immobilized 32% unreliable, 28% distracting injury, 6% abnormal neuro, 54% spine pain/tenderness 7 acute fractures All were immobilized Burton. Prehospital Emergency Care. 2005.

Prehospital Clearance 13,357 patients, 415 (3%) with spine injuries Nexus criteria Sensitivity was 92% Nonimmobilization of 33 (8% ) patients with spine injuries. None sustained cord injuries. Domeier. Ann Emerg Med. 2005

Prehospital Clearance Retrospective chart review 861 C-spine injuries, 504 brought by EMS 495 had C-spine immobilization 2 refused, 2 could not be immobilized 3 missed by protocol, 2 protocol violations 1 adverse outcome, 2 unstable Four over age 67, one under 1 year Stroh. Can an out-of-hospital cervical spine clearance protocol identify all patients with injuries? Annals of Emerg Med. 2001

Consensus Statement “Implementation of clinical criteria for cervical spinal clearance in out-of-hospital setting is not well validated by multicenter studies or accepted by many emergency departments.” “This group recommends that clinical criteria to determine “low-risk” patients be available to EMS providers.” Hankins. Prehospital Emergency Care. 2001.

Conclusion Canadian C-spine Rules better than Nexus Low-Risk Criteria Prehospital C-spine clearance in controversial