Evaluation of the Canadian C-Spine Rule Continues

Posted by Patrick Lickiss on Jul 27, 2011 in Assessment, General, Research, Treatment | 2 comments

In an article published in February in the BioMed Central of Emergency Medicine (an OPEN journal by the way, not charging $85/article!) a study protocol was laid out for the next phase in the evaluation of the safety of the Canadian C-Spine Rule (CCR).  The full text of the article may be found here (PDF link).

For those not familiar, the CCR is a spinal clearance tool which is basically a cross between the State of Maine and the NEXUS criteria you’ve likely seen physicians use in the ED.  There’s a nice flow chart in the article, but the basics are as follows:

• Does the patient have a high risk factor indicating immobilization?
  • Older than 64 years
  • Dangerous mechanism
  • Numbness/tingling
• Does the patient have one low risk factor?
  • Minor rear-end MVC
  • Ambulatory on scene
  • No neck pain when asked
  • No neck pain with palpation
• Can the patient rotate their own head, left and right, to 45 degrees, regardless of pain

I really like this technique because it just makes sense:  Do they have any big things to worry about?  No.  Do they have something which indicates they’re uninjured? Yes.  Can they move their head? Yes.  Fantastic, don’t c-spine!

A BRIEF HISTORY OF THE CCR
The researchers in Canada have clearly been doing their due diligence.   This project has been on going, in one form or another, for the past 10+ years.  The CCR was first written about in 2001 and was compared at the time to both the standard NEXUS exam and radiological results.  Since then, the procedure has been validated amongst physician, ED triage nurse and paramedic level practitioners.  During the phase I and II trials, the CCR demonstrated a 99.7% sensitivity ^[1].

The researchers have since implemented the protocol amongst physicians in  multiple hospitals and are studying implementation amongst ED triage nurses as well.  One line in the article really stuck in my head after reading it:  ”While we hope to demonstrate that ED triage nurses can safely remove patient’s cervical immobilization devices, it would be significantly more valuable if we could empower the paramedics to selectively forgo immobilization in the first place, and avoid great discomfort to patients.” ^[1] Simply put, I love this idea!  If we have access to a tool which can benefit our patients, why don’t we give it to everyone involved in patient care, so that we can significantly benefit our patients more often!

Additionally, I love the idea of standardizing something like ruling out spinal immobilization across all levels of care from pre-hospital to in-hospital.  The main thing holding this article/study back from being one of the most ground breaking in EMS is the actual statement that spinal immobilization is not, in fact, beneficial and actually harms our patients.  But that might be asking too much.

At any rate, check out the article and stay tuned, the idea of standardizing care across practitioner levels is an interesting one that bears more reflection.

ARTICLE CITED
[1] - Vaillancourt C, et. al: “Evaluation of the safety of C-spine clearance byparamedics: design and methodology”. BMC Emergency Medicine 2011 11:1.

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