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Should Medics Clear C-Spine in the Field?

December 7, 2022

Written by Amanda Mathews

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In this large, single-center prospective cohort implementation study, paramedics were able to apply a modified* Canadian C-spine rule to assess low risk trauma patients and transport a large proportion of them to a higher level of care without spinal precautions.

Why does this matter?
Trauma patients are often transported in full spinal precautions (cervical collar + backboard), which can cause not only discomfort to the patient but other adverse events, such as pressure wounds, aspiration events, and neck vein compression. What if there was a way to safely determine which patients truly needed cervical spine immobilization prior to hospital arrival?

Hey doc, when can I get this collar off?
The aim of this study was to evaluate the safety and accuracy of a modified Canadian C-spine rule for use by advanced and primary care paramedics in low risk trauma patients. Low risk patients had GCS of 15 and stable vital signs. The primary measurement was the proportion of patients transported without spinal immobilization. Eligible patients (4,034) were those who had a blunt trauma mechanism with neck pain and/or visible injury above the clavicle and/or mechanism that could cause neck injury (provider discretion). 

2,583 immobilizations were avoided using the modified rule. 952 patients (23.6%) received diagnostic imaging; of those, only 11 clinically important injuries were found. One of those injuries were missed by the prehospital providers when applying the modified rule, but no adverse outcome was reported.

While this study was limited by the low number of clinically significant injuries in the study cohort, it is impressive how many patients were safely transported without spinal immobilization. It can take hours to clear a cervical collar in a crowded ED, so interventions in the pre-hospital setting may be our answer in preventing adverse outcomes associated with prolonged immobilization.

*The modification was removal of two parts of the CCSR: “sitting position in the emergency department” and “delayed onset of neck pain.”

Implementation of the Modified Canadian C-Spine Rule by Paramedics. Ann Emerg Med. 2022 Oct 31:S0196-0644(22)01030-7. doi: 10.1016/j.annemergmed.2022.08.441. Epub ahead of print.

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