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Vaillancourt, MD and his colleagues recently published an article in
the journal Annals of Emergency Medicine (2009;54:663-671) entitled
"The Out-of-Hospital Validation of the Canadian C-Spine Rule by
Paramedics." This rule was originally developed for "clinical
clearance" (e.g., without the use of x-rays) of persons with possible
cervical spine fracture (broken neck) in alert and stable trauma
patients by qualified persons (generally, emergency physicians) in a
health care setting (such as an emergency department). This particular
study found that paramedics can apply the Canadian C-Spine Rule
reliably, without missing important cervical spine injuries.
Rule, properly applied to an awake and alert injured person for which
there is a concern for a cervical spine injury, provides the following
1. If a person has a high-risk factor (age greater
than or equal to 65 years; a dangerous mechanism of injury [a fall from
an elevation greater than or equal to 3 feet; fall down 5 or more
stairs; direct blow to top of head, such as a diving board accident;
motor vehicle accident characterized by high speed, rollover or
passenger ejection; motorized recreational vehicle accident; bicycle
collision]; or numbness/tingling in an arm or leg), then neck
immobilization and x-rays are indicated.
2. If the victim is not
able to actively rotate his or her neck, under their own power and
without assistance, 45 degrees to the left and right without causing
pain, then neck immobilization and x-rays are indicated. If the victim
is completely without pain at rest and on active range of motion of the
neck, then it is unlikely that an unstable fracture is present.
Low-risk accident factors that allow safe assessment of range of motion
of the neck include simple rear-end motor vehicle collision (excludes
being pushed into oncoming traffic, being hit by a bus or large truck,
rollover, or hit at high speed by a vehicle); person is capable of a
sitting position; person is ambulatory (e.g., walking); delayed onset
of neck pain; and absence of posterior or anterior pain on examining
(e.g., pressing upon) the neck. If the accident is deemed to be
low-risk, then the victim is asked to attempt rotation of his or her
neck under their own power and without assistance. See number 2 above.
does this mean for the layperson who is practicing medicine in the
outdoors? It provides a very reasonable approach to deciding who might
be safely examined and when to apply a cervical spine immobilization
technique. The overall goal is to not move someone's neck if he or she
might have an unstable fracture, where movement could jeopardize the
integrity of the spinal cord. Clinical judgment and intuition serve
important roles, because it truly is best to always err on the side of
"better safe than sorry." However, if the victim is low risk from all
perspectives, it allows the rescuers more comfort in moving the victim
or allowing self-extrication from a difficult situation or hostile
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