Transcript Document

An audit of cervical spine
imaging in alert and stable
trauma patients
Yenzhi Tang, Marianna Thomas, Mike Spiro
Foundation Year 2 Doctors in Emergency Medicine
Accident and Emergency Department, Whittington Hospital, London
January 2007
Aim
To compare assessment and C spine
radiography in alert stable patients with
head/neck trauma presenting to
Whittington Hospital Emergency
Department, to Canadian C spine rules
for radiography
Current Practice
No guidelines on the Whittington
intranet
No NICE guidelines
No current proforma/standard for
assessing pts at risk of C spine fracture
Standard
Target level 100%
Canadian C spine rules
Background
Canadian C spine rule developed from
a prospective cohort of alert, stable
patients with head/neck trauma.
Pts from 10 Canadian EDs between
1996-1999. (n=8924)
Developed in response to wide variation
in indications for requesting C spine x
rays
Background
Prospectively validated in a large
multicentre trial (n=7017)
99.3% sensitivity (95% CI 96-100)
Specificity 45.1%
Shown to be superior to NEXUS by
prospective study by Stiell
Audit
Population

Adults presenting to ED with blunt trauma
to head/neck, stable vital signs, GCS 15
Audit
Exclusions
Known vertebral disease
 Pregnant women
 <16
 >48 h after injury
 Penetrating trauma
 Acute paralysis

High risk group
>65
Paraesthesia in extremities
Dangerous mechanism
Fall from >1 metre or stairs
 Axial load to head
 MVC at high speed >62mph
 Motorized recreational vehicles
 Bicycle collisions

Low Risk Group
Should have C spine ROM assessed if
walking, sitting, nil c spine tenderness,
nil paraesthesia
If less than 45 degrees rotation to each
side then X ray
If full ROM then no radiography
Method
Retrospective audit
Pts selected from a 3 week period
Case note analysis
EDIS used to identify pts triaged with
neck pain/head injury/neck strain/ RTA
Results
36 pts over 3 weeks
5 excluded
4 not meeting criteria
 1 set of notes not found

Results
In the high risk group (total 8) 5 had x
rays
No fractures imaged in all 5 x rays
 None of the X rays were adequate views,
none had C1 –T1. None were repeated or
had subsequent CT spine

Results
Low Risk group
One pt had x ray
 No fractures
 Difficult to interpret ED performance b/c of
lack of documentation

Conclusions
Poor documentation

9/22 in low risk group did not document ROM
Poor knowledge and application of C spine
rules



3/10 ED doctors have heard of C spine rules
1/10 have used it
1/10 know the algorithm
Conclusions
Radiographers need to be informed of
their inadequate views

-can present findings to radiographers
SHO competent in interpreting c spine x
rays
Rules open to interpretation: low risk
criteria?
PLAN
Present findings to ED doctors,
emphasize need for better
documentation
Put algorithm in majors and minors desk
Incorporate rules into Whittington ED
head proforma
Re audit in 3-6 months
References
Stiell IG, Wells GA, Vandemheen KL,
Clement CM, Lesiuk H, De Maio VJ, et al.
The Canadian C-spine rule for radiography in
alert and stable trauma patients. JAMA.
2001;286:1841–1848.
Stiell et al Acad Emerg Med 2002 Volume 9,
Number 5 359-360
Hoffman et al Ann Emerg Med 1992; 21 (12):
1454-60
Stiell et al NEJM Vol 349: 2510-2518 (2003)