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

2. 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?

3. 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.

4. 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

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

6. 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.

7. ED Literature

8. 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

9. 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.

10. 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.

11. 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

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

13. 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

14. Prehospital Clearance

15. 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

16. 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

17. 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.

18. 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

19. 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

20. 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

21. 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:

22. 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

23. 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

24. 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

25. 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

26. 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

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