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)