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An audit of cervical spine imaging in alert and stable trauma patients
Accident and Emergency Department, Whittington Hospital, LondonJanuary 2007
Yenzhi Tang, Marianna Thomas, Mike SpiroFoundation Year 2 Doctors in Emergency Medicine
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
PopulationAdults presenting to ED with blunt trauma
to head/neck, stable vital signs, GCS 15
Audit
ExclusionsKnown vertebral diseasePregnant women<16>48 h after injuryPenetrating traumaAcute paralysis
High risk group
>65Paraesthesia in extremitiesDangerous mechanismFall from >1 metre or stairsAxial load to headMVC at high speed >62mphMotorized recreational vehiclesBicycle 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 excluded4 not meeting criteria 1 set of notes not found
Results
In the high risk group (total 8) 5 had x raysNo fractures imaged in all 5 x raysNone of the X rays were adequate views,
none had C1 –T1. None were repeated or had subsequent CT spine
Results
Low Risk groupOne pt had x rayNo 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 5 359-360Hoffman et al Ann Emerg Med 1992; 21 (12): 1454-60Stiell et al NEJM Vol 349: 2510-2518 (2003)
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