There are several, validated clinical decision rules. The Canadian C-spine rule and NEXUS are the two most clinically utilised in Australia. These two clinical decision tools help you to decide who needs radiology to rule out a significant cervical spine injury.
Have a working understanding of both rules. Whichever rule you chose to apply, complete all the components of that rule.
If a patient passes either rule they can be cleared clinically without injury. Specifically, the NEXUS rule allows you to clear patients with a serious mechanism of injury if they are symptoms free, where as The Canadian rules do not. However, the Canadian rules allow you to clear a patient with neck pain if they have low risk features, where as the NEXUS rule does not.
- 8900 patients. 100% sensitive, 42.5% specific.
NEXUS (National Emergency X-Radiography Utilization Study)
- >34,000 patients. It only included a very small number of infants, so be careful about applying rules to the paediatric populations.
- Found to be 99% sensitive for detecting ANY injury, 99.6% specific for detecting ‘significant’ injury. However, in patients >65 years, sensitivity dropped to only 89% for clinically significant injury.
- 12.9% specific.
In recent years there has been increasing discussion around the use of spinal immobilisation both pre and in hospital, in particular the use of the rigid cervical collar and the evidence behind it (1-6).
There is no scientific evidence that any type of cervical collar used in prehospital transport or initial trauma management is effective in stabilising an acutely injured cervical spine or preventing further neurological deterioration in those with spinal cord injury (7). However, there is evidence that rigid collars can lead to significant complications and morbidity when used to secure the c-spine.
These complications include (11-13):
- Pressure areas of the scalp and neck
- Increased pain adversely affecting compliance with immobilisation strategies designed to protect patients from further harm
- Impaired jugular venous return and rises in intracranial pressure both in head-injured and healthy people
- Impaired respiratory effort and forced expiratory volume, particularly in older patients with chest injury or comorbid respiratory conditions, predisposing these patients to aspiration
- Increased complexity of airway management
- Increased extrication time and delay to definitive treatment
Evidence indicates that we are unable to completely immobilise the C spine in any collar and there is no data to support that any additional movement of an injured C spine causes more damage (13, 14).
After consultation with specialist clinicians across NSW and consideration of the available evidence, The Institute of Trauma and Injury Management (ITIM) and ECI have concluded that the risks of immobilisation with rigid collars outweigh the chance of benefit.
ITIM and ECI are advocating for the adoption of foam cervical collars in the initial management of injured adults and children requiring cervical spine precautions being transported by NSW Ambulance and presenting to NSW Health facilities.
For more information, please read our Position Statement on maintaining cervical spine precautions. This statement also covers application of foam collars in a variety of clinical scenarios.
Autonomic dysreflexia is a medical emergency that can occur in people with spinal cord injury at or above the sixth thoracic (T6) level. It is a sudden and severe rise in blood pressure resulting from overactivity of an isolated sympathetic nervous system below the lesion, triggered by a nociceptive stimulus that can result in intracranial haemorrhage, fits, arrhythmias, hypertensive encephalopathy and even death. This potentially life-threatening condition requires immediate and decisive action. Below are some useful links to assist in the management of this condition in the emergency department:
Autonomic Dysreflexia Medical Emergency Card
Autonomic Dysreflexia Algorithm
Treatment of Autonomic Dysreflexia for Adults and Adolescents with Spinal Cord Injuries (updated 2014)
Video Presentation on Autonomic Dysreflexia by Dr James Middleton
Autonomic Dysreflexia in adults with spinal cord injuries - HETI module - only accessible to NSW Health employees
Safety Notice 14/10 - Autonomic Dysreflexia (revised) 2010
Management of the Neurogenic Bladder for Adults with Spinal Cord Injuries
Management of the Neurogenic Bowel for Adults with Spinal Cord Injuries
References and further resources