Review of: Vaillancourt C, Stiell IG, Beaudoin T, et al. The out-of-hospital validation of the Canadian C-Spine Rule by paramedics. Ann Emerg Med. 2009;54:663–667.
This prospective study of the Canadian rule was developed to facilitate the clearance of the cervical spine (C-spine) in the alert and stable trauma patient. The investigators note the rule had been previously validated by emergency physicians in more than 8,000 patients.
Seven Canadian regions participated in this study, which included alert and stable adult trauma patients who could have potentially sustained a neck injury. Basic- and advanced-care paramedics took part in this study. Patients were evaluated by these paramedics, then immobilized and evaluated in the emergency department to determine the outcome—a clinically significant C-spine injury.
Approximately 1,949 patients were included in this study. Motor vehicle crashes were the greatest mechanism of trauma with 62.5% of all injuries, followed by falls at 19.9%. The percentage of patients admitted to the hospital was 10.9%, and .06% (n=12) sustained a clinically significant neck injury. Paramedics were able to identify all 12 patients with a clinically significant neck injury. Providers misinterpreted the algorithm in 320 patients (those who were immobilized but didn’t need to be) and were comfortable with using the algorithm in 1,594 patients. A total of 731 patients, after evaluation, could have been spared immobilization.
The investigators found paramedics were capable of applying the Canadian rule without missing a clinically significant C-spine injury. Thus, adoption of the rule could spare a significant number of immobilizations.
The rule continues to be validated. Although Marshall is ready to adopt them without question, Dr. Wesley believes additional research is needed to better define some of the parameters.
Medic Marshall: I have one thing to say about this study … finally! Have you ever come upon a scene of a simple, rear-end accident? Let's say the accident occurred at 10 mph, and the 30-year-old patient who was rear-ended is now walking around groaning, claiming they have excruciating back pain. Well, that might be a little much, but you get the point. Regardless, now you're stuck trying to figure out if this is a real injury. Well, let's work through the steps.
Is there any one high risk factor that mandates immobilization? Ask yourself:
- Is the patient more than 65? No.
- Did the accident involve a dangerous mechanism? No.
- Does the patient have numbness or tingling? No.
Now, is there any one low risk factor that allows safe assessment of range of motion?
- Was the accident a simple rear end? Yes.
- Is the patient ambulatory on scene? Yes.
- Does the patient report no neck pain on scene? Yes.
- Is there absence of mid-line C-spine tenderness? Yes.
- Is the patient voluntarily able to actively rotate their neck 45 degrees left and right when requested, regardless of pain?
You've just determined that this patient does not require spinal immobilization, which is good. Lying on a hard, plastic surface with a tight, plastic collar around your neck isn't comfortable and in leads to increased discomfort for the patient. So, in my humbled opinion, I believe we should begin to adopt some sort of selective spinal immobilization protocol, if you haven't already. It will save you, and your back, while sparing the patient undue discomfort.
Doc Wesley: Marshall and I are in total agreement on this one. The area that's frequently overlooked is the presence of a distracting injury, which would make the patient fail to recognize the presence of neck pain. Unfortunately, no research has been done to define "distracting injury". I've generally considered this to be something like a long bone fracture, significant soft-tissue injury, and of course, any head injury with altered loss of consciousness.
This question needs to be addressed in future studies so that we can better further the process of selective spinal immobilization.