> Yes, so even in the presence of mechanism, if none of the others are
> present (pain, head injury, alcohol, etc.), can clinically exclude
> c-spine injury.
>
> Quite a robust debate at the moment about the risk with
> elderly patients
> with osteoporosis - having said which, we go to literally of 1000's of
> Falls a year, the majority of whom are not immobilised in the elderly,
> even prior to the introduction of the protocol.
It's interesting that the rule was thought to reduce x-rays cf. the NEXUS
rules (which seem to be broadly what you are using- all 5 of absence of
midline tenderness; fully alert; not intoxicated; no abnormal neurology; no
distracting injury), but would have us x-ray purely on the basis of
mechanism or of the patient being over 65. Radiologists don't like it if we
send patients for neck films without immobilisation (seems reasonable); so
it seems strange if an ambulance service is transporting patients without
immobilisation and they are then collared and x-rayed in A and E- if this
happened to me as a patient I'd wonder what was going on.
Having said that, Steill did feel that the NEXUS rules not only over
x-rayed, but were not sensitive enough (based on a retrospective validation
that found 10 of 148 clinically important injuries were missed. (Reference:
Steill et al. Application of the NEXUS Low- risk Criteria for cervical spine
radiography in Canadian emergency departments. Acad Emerg Med 2000; 7: 566)
and furthermore that intoxication and distracting injury were poorly
reproducible. Having said that, the NEXUS rules were validated in a
different 34, 000 patient study in which on 8 of 818 cervical spine injuries
were missed (ref: Hoffman et al. Validity of a set of clinical criteria to
rule out injury to the cervical spine in patients with blunt trauma. NEJM
2000; 343: 94-99).
So, EAST, NEXUS or Canadian rules- or something else. What's being used? Are
ambulance services using any rules, and if so are they adaptations of rules
for x-ray (Anyone want to do a proper survey and get a paper out of it?)
Matt Dunn
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