You and your partner arrive at the scene of a motor vehicle accident and find a lone vehicle with moderate front-end damage crashed into a tree. The air bag has deployed and there is no one in the car. You find the sole occupant standing on the sidewalk talking with a bystander. Your partner secures the man's neck with manual stabilization.
During your assessment, the patient complains of left knee pain, but he is bearing weight on it with a symmetrical gait. He denies having had anything to drink. You palpate his cervical spine, and he denies any pain or tenderness. He has symmetrical grip strength and is able to feel his fingers when questioned. You ask him to rotate his neck, and he is able to do so without pain. The patient agrees to go to the hospital and is transported sitting upright on the gurney without spinal precautions.
New Criteria Developed
Immobilizing a patient used to be such a simple decision. No matter how trivial the mechanism of injury, you strapped the patient down on the backboard and transported him to the emergency department, where he lay flat on his back--unable to move--until an x-ray technician took a picture of his neck. Since a lot of patients have some sort of blunt trauma mechanism, that means we used a lot of backboards and shot a lot of x-rays.
A few years ago, emergency departments in the United States and Canada began looking for ways to reduce the resources used for patients with little chance of actual injury.1 Reduced imaging served to decrease unnecessary costs and patient exposure to radiation. A set of criteria was created to measure the potential for cervical spine injury in patients with blunt force trauma.
The National Emergency X-Radiology Utilization Study (NEXUS) group's low-risk criteria were developed as the tool used to determine the need for patients to receive x-rays.2 This tool was specifically proposed to reduce the use of x-ray to rule out cervical spine injury and was not originally intended for prehospital providers to make decisions about immobilization in the field. As a tool to decrease unnecessary x-rays, it was shown to be an effective device.3
There are potential risks associated with prolonged spinal immobilization, particularly regarding pain and discomfort for the patient.4 With a similar aim to decrease unnecessary use of resources and patient discomfort, some EMS systems in the United States and elsewhere have developed protocols allowing prehospital providers discretion in applying spinal precautions to patients with blunt trauma mechanisms of injury. Many of these algorithms use the NEXUS low-risk criteria as their basis, and some have added elements of another clinical c-spine clearance process--the Canadian C-Spine Rule.5
There has been some trepidation about providing these protocols to nonphysician caregivers outside the hospital; however, evidence shows that prehospital personnel can adequately determine which patients require cervical spine immobilization.6 The majority of emergency physicians believe adequately trained prehospital personnel should be able to clinically determine the need for spinal precautions.7 Despite that confidence, comparing the ability of prehospital personnel to emergency department physicians has shown mixed success.8,9 The best correlation between physicians and paramedics was accomplished using simulated patients in a standard setting.10 Indeed, a similar study using only simulated patients revealed that EMT-Basics and lay college students could adequately choose which patients to immobilize.11 These types of studies may not accurately reflect the tendencies of field providers when determining the need for immobilization. The reality is that prehospital personnel perform in a dynamic environment distinctly different from that of the emergency department.