C-spine Injury Research Articles

Clinical clearance of the cervical spine in patients with distracting injuries

The purpose of this study was to prospectively assess the sensitivity and efficacy of clinical examination for screening of cervical spine (c-spine) injury in awake and alert blunt trauma patients with concomitant "distracting injuries." During the 24-month period from December 2009 to December 2011, all blunt trauma patients older than 13 years were prospectively evaluated with a standard cervical spine examination protocol by the trauma surgery team at a Level 1 trauma center. Awake and alert patients with a Glasgow Coma Score (GCS) ≥14 underwent clinical examination of the cervical spine. Clinical examination was performed regardless of "distracting injuries." Patients without complaints of pain or tenderness on physical exam had their cervical collar removed, and the c-spine was considered clinically cleared of injury. All awake and alert patients with "distracting injuries," including those clinically cleared and those with complaints of c-spine pain or tenderness underwent computerized tomographic (CT) scanning of the entire c-spine. "Distracting injuries" were categorized into three anatomic regions: head injuries, torso injuries and long bone fractures. Patients with minor distracting injuries were not considered to have a "distracting injury." During the 24-month study period, 761 blunt trauma patients with GCS ≥14 and at least one "distracting injury" had been entered into the study protocol. Two-hundred ninety-six (39%) of the patients with "distracting injuries" had a positive c-spine clinical examination, 85 (29%) of whom were diagnosed with c-spine injury. Four hundred sixty-four (61%) of the patients with "distracting injuries"’ were initially clinically cleared, with one patient (0.2%) diagnosed with a c-spine injury. This yielded an overall sensitivity of 99% (85/86) and negative predictive value greater than 99% (463/464) for cervical spine clinical examination in awake and alert blunt trauma patients with "distracting injuries." In the awake and alert blunt trauma patient with "distracting injuries," clinical examination is a sensitive screening method for cervical spine injury. Radiological assessment is unnecessary for safe clearance of the asymptomatic cervical spine in awake and alert blunt trauma patients with "distracting injuries." These findings suggest the concept of "distracting injury" in the context of cervical spine clinical examination is invalid. Expanding the utility of cervical spine clinical examination to patients with "distracting injuries" allows for significant reduction of both healthcare cost and radiation exposure.

Airway management practices in adult intensive care units in Israel: a national survey

Timely and adequate management of normal and compromised airway is a crucial task facing medical teams taking care of patients in intensive care units. We investigated the airway management practices in the Israeli intensive care units (ICUs). A postal survey was sent to the 20 main ICUs in Israel. We investigated which medical specialty (ICU, anesthesiology or ENT) is involved with airway management in the ICUs and summarized the availability of airway equipment and medication necessary for endotracheal intubation, the use of dedicated airway management algorithms, the approaches to specific airway scenarios and education in airway management. The response rate was 70 % (14 out of the 20 units). Intubation with normal airway is performed mainly by ICU doctors (86 %). A difficult airway is most frequently cared for by anesthesiologists (79 %), while impossible intubation/mask ventilation is mainly managed by anesthesiologists and ENT surgeons (50-79 %). Airways in C-spine injury are mainly managed by anesthesiologists (70 %). Surgical airway is mainly performed by ENT surgeons (79 %). The ASA difficult airway algorithm is used in 71 % of the units. Fiberoptic intubation is used significantly more often than other methods in two scenarios: 78 % of the difficult airways and 64 % of the C-spine injuries (p < 0.0001). Only 43 % of the units reported holding quality assurance meetings. 69 % of the units' heads are satisfied with their airway management policies. Equipment and medications necessary for airway management are available in most of the units. Difficult airways in ICUs are mainly managed by anesthesiologists and ENT surgeons. Few ICUs have quality assurance meetings.

Cervical spine injuries and helmet laws

To assess the incidence of cervical spine (C-spine) injuries in patients admitted after motorcycle crash in states with mandatory helmet laws (MHL) compared with states without helmet laws or selective helmet laws. The Nationwide Inpatient Sample from the Healthcare and Utilization Project for the year 2008 was analyzed. International Classification of Diseases and Health Related Problems, Ninth Edition codes were used to identify patients with a diagnosis of motorcycle crash and C-spine injuries. National estimates were generated based on weighted analysis of the data. Outcome variables investigated were as follows: length of stay (LOS), in-hospital mortality, hospital teaching status, and discharge disposition. States were then stratified into states with MHL or selective helmet laws. A total of 30,117 discharges were identified. Of these, 2,041 (6.7%) patients had a C-spine injury. Patients in MHL states had a lower incidence of C-spine injuries (5.6 vs. 6.4%; p = 0.003) and less in-hospital mortality (1.8 vs. 2.6%; p = 0.0001). Patients older than 55 years were less likely to be discharged home (57.5% vs. 72.5%; p = 0.0001), more likely to die in-hospital (3.0% vs. 2.1%; p = 0.0001), and more likely to have a hospital LOS more than 21 days (7.7% vs. 6.2%; p = 0.0001). Patients admitted to the hospital in states with MHLs have decreased rate of C-spine injuries than those patients admitted in states with more flexible helmet laws. Patients older than 55 years are more likely to die in the hospital, have a prolonged LOS, and require services after discharge. III.

Can a Rescuer or Simulated Patient Accurately Assess Motion During Cervical Spine Stabilization Practice Sessions?

Health care providers must be prepared to manage all potential spine injuries as if they are unstable. Therefore, most sport teams devote resources to training for sideline cervical spine (C-spine) emergencies. To determine (1) how accurately rescuers and simulated patients can assess motion during C-spine stabilization practice and (2) whether providing performance feedback to rescuers influences their choice of stabilization technique. Crossover study. Training studio. Athletic trainers, athletic therapists, and physiotherapists experienced at managing suspected C-spine injuries. Twelve lead rescuers (at the patient's head) performed both the head-squeeze and trap-squeeze C-spine stabilization maneuvers during 4 test scenarios: lift-and-slide and log-roll placement on a spine board and confused patient trying to sit up or rotate the head. Interrater reliability between rescuer and simulated patient quality scores for subjective evaluation of C-spine stabilization during trials (O = best, 10 = worst), correlation between rescuers' quality scores and objective measures of motion with inertial measurement units, and frequency of change in preference for the head-squeeze versus trap-squeeze maneuver. Although the weighted κ value for interrater reliability was acceptable (0.71-0.74), scores varied by 2 points or more between rescuers and simulated patients for approximately 10% to 15% of trials. Rescuers' scores correlated with objective measures, but variability was large: 38% of trials scored as 0 or 1 by the rescuer involved more than 10° of motion in at least 1 direction. Feedback did not affect the preference for the lift-and-slide placement. For the log-roll placement, 6 of 8 participants who preferred the head squeeze at baseline preferred the trap squeeze after feedback. For the confused patient, 5 of 5 participants initially preferred the head squeeze but preferred the trap squeeze after feedback. Rescuers and simulated patients could not adequately assess performance during C-spine stabilization maneuvers without objective measures. Providing immediate feedback in this context is a promising tool for changing behavior preferences and improving training.

Airway management in the patient with potential cervical spine instability: Continuing Professional Development

Securing the airway of a patient with a potentially unstable cervical spine (C-spine) is a complex and challenging task. The objective of this continuing professional development module is to review the current knowledge essential for airway management in the face of potential C-spine instability and, at the same time, to underline areas of uncertainty and limitations in the literature. In low-risk patients-defined by strict criteria derived from large multicentre studies-the C-spine can be considered stable or "cleared" without imaging. In all other patients, at least a thin-section computed tomographic examination of the spine from the occiput to T1 should be obtained, including sagittal and coronal multiplanar reconstructed images. Until the C-spine is cleared, it should be immobilized in the neutral position using a rigid cervical collar, sandbags, tape, and a backboard. During airway management, the anterior part of the cervical collar should be removed, and manual in-line stabilization should be applied. Some airway techniques, such as fibreoptic bronchoscopy and the Trachlight(®), have been shown to induce less C-spine movement than direct laryngoscopy; however, the impact of such airway management on outcome is uncertain. Adequate airway management in the patient with potential C-spine injury demands an understanding of C-spine anatomy, the criteria required to clear the C-spine, and the indications, techniques, and pitfalls of C-spine immobilization. When choosing an airway technique, minimization of C-spine motion should be considered, but the method of choice should also incorporate the broader clinical context.

The Presence of Nonthoracic Distracting Injuries Does Not Affect the Initial Clinical Examination of the Cervical Spine in Evaluable Blunt Trauma Patients: A Prospective Observational Study

A distracting injury mandates cervical spine (c-spine) imaging in the evaluable blunt trauma patient who demonstrates no pain or tenderness over the c-spine. The purpose of this study was to examine which distracting injuries can negatively affect the sensitivity of the standard clinical examination of the c-spine. This is a prospective observational study conducted at a Level I Trauma Center from January 1, 2008, to December 31, 2009. After institutional review board approval, all evaluable (Glasgow Coma Scale score ≥13) blunt trauma patients older than 16 years sustaining a c-spine injury were enrolled. A distracting injury was defined as any immediately evident bony or soft tissue injury or a complaint of non-c-spine pain whether or not an actual injury was subsequently diagnosed. Information regarding the initial clinical examination and the presence of a distracting injury was collected from the senior resident or attending trauma surgeon involved in the initial management. During the study period, 101 evaluable patients sustained a c-spine injury. Distracting injuries were present in 88 patients (87.1%). The most common was rib fracture (21.6%), followed by lower extremity fracture (20.5%) and upper extremity fracture (12.5%). Only four (4.0%) patients had no pain or tenderness on the initial examination of the c-spine. All four patients had bruising and tenderness to the upper anterior chest. None of these four patients developed neurologic sequelae or required a surgical stabilization or immobilization. C-spine imaging may not be required in the evaluable blunt trauma patient despite distracting injuries in any body regions that do not involve the upper chest. Further definition of distracting injuries is mandated to avoid unnecessary utilization of resources and to reduce the imaging burden associated with the evaluation of the c-spine.

Prehospital improvisation of standard oxygen therapy equipment to facilitate delivery of a bronchodilator in a supine patient

A police request was made to the ambulance service to attend an adult victim of an alleged assault. On arrival the patient was found to be alert (AVPU: alert, responds...

Using cervical spine clearance guidelines in a pediatric population: a survey of physician practices and opinions

Unlike in adults, there are currently no standardized, validated guidelines to aid practitioners in clearing the pediatric cervical spine (C-spine). Many pediatric centres in Canada have locally produced, adult-modified guidelines, but the extent to which these or other guidelines are used is unknown. The purpose of this study was to determine if Canadian physicians are using either locally produced or adult C-spine guidelines to clear the C- spines of patients < 16 years of age. The study also characterized the common methods used by physicians to clear pediatric C-spine injuries in terms of clinical examination and radiologic imaging. A 20-question survey was distributed to 240 Canadian pediatric emergency physicians and trauma team leaders using the Dillman Total Design Method. The response rate was 68%. The results showed that 61% of physicians currently use guidelines to assist in the clearance of pediatric C-spines. Of those physicians not using guidelines, 85% stated that they would use them if they were available. The clinical criteria most often used to clear pediatric C-spines were a normal neurologic examination (97%) and the absence of C-spine tenderness (95%), intoxication (94%), and distracting injuries (87%). Guidelines are commonly used by Canadian physicians when clearing the pediatric C-spine, yet few are validated in children. Those most commonly used are locally developed guidelines, the Canadian C-spine guidelines, or National Emergency X-Radiography Utilization Study (NEXUS) low-risk criteria.

Validation of the Canadian c-spine rule in the UK emergency department setting

AimTo determine the potential of the Canadian Cervical Spine Rule (CCR) to safely reduce the number of cervical spine (c-spine) radiographs performed in the UK emergency department setting.MethodsThe study was...

Cervical Spine Clearance in Obtunded Blunt Trauma Patients: A Prospective Study

This prospective study of 402 obtunded blunt trauma patients compared the accuracy of computed tomography (CT) scanning vs. dynamic radiographs for the detection of unstable cervical spine (C-spine) injuries. Patients included in the study underwent both a CT scan and flexion-extension radiographs of the C-spine. There was one injury that was missed on CT scan but detected on dynamic radiographs, resulting in a percentage of missed injury of 0.25%. Subsequent independent review of the CT scan showed that pathologic changes indicative of injury were present on the initial CT scan.

Frequent Computed Tomography Scanning Due to Incomplete Three-View X-Ray Imaging of the Cervical Spine

Conventional C-spine imaging (3-view series) is still widely used in trauma patients, although the utilization of computed tomography (CT) scanning is increasing. The aim of this study was to analyze the value of conventional radiography and the frequency of subsequent CT scanning due to incompleteness of three-view series of the C-spine in adult blunt trauma patients. We analyzed the data of a prospectively collected database including all patients between November 2005 and November 2007 treated in the trauma resuscitating room. We assessed the reasons for subsequent CT scanning after the three-view series according to the following classification: inevaluability, incompletion, evaluation of findings on three-view series or evaluation of unexplained, and persistent clinical symptoms. Furthermore, we evaluated possible predictors for incompleteness. Of 1,283 blunt trauma patients, 88 C-spine injuries were diagnosed with an overall incidence of 6.9%. One hundred fifty-nine patients (12%) had their C-spine cleared based on the NEXUS criteria and 12 died before C-spine imaging could be performed. A total of 717 patients were primarily evaluated with three-view series and 395 patients primarily with CT scanning. Within the population with primarily three-view series, 249 (35%) were repeatedly incomplete and 16 (2%) were inevaluable. In the majority of the incomplete three-view series, no apparent reason could be determined. However, the presence of clavicular fractures (resulting in incomplete radiographs in 68% vs. 34% without a fracture; p < 0.001) and rib fractures (56% vs. 34%; p = 0.008) were associated with incomplete three-view series. In more than one third of the patients primarily assessed with three-view X-ray series of the C-spine, the results are incomplete or inevaluable necessitating CT scanning. Although the majority of the incomplete series remain unexplained, we advise CT scanning in patients having clavicular and rib fractures because this increases the likelihood of obtaining incomplete three-view series.

A Nationwide Review of the Associations Among Cervical Spine Injuries, Head Injuries, and Facial Fractures

: Several small studies have investigated the relationship among facial fractures, c-spine injuries, and head injuries with varying results. Determining this correlation at a national level would be the first step in updating the trauma imaging protocol. The purpose of this study was to review the incidence of facial fractures, c-spine injuries, and head injuries at trauma centers across the United States. : The design was a retrospective chart review of International Classification of Disease, Ninth Revision, diagnosis and procedure codes from the National Trauma Data Bank between the years 2002 and 2006. This included data on more than 2.7 million reported traumas. : The incidence of facial fracture was 13.5% in patients with a c-spine injury, 21.7% in patients with a head injury, and 24.0% of patients with a combined c-spine and head trauma. Head injuries were found in 40.2% of patients with a c-spine injury, 67.9% of patients with a facial fracture, and 71.5% of patients with a combined c-spine injury and facial fracture. C-spine injuries were reported in 6.7% of facial fractures, 7.0% of head injuries, and 7.8% of patients with a combined facial fracture and head injury. : This is the largest review in history documenting these associations. Pending cost-benefit analysis, the current trauma imaging protocol may be challenged.

Cervical Spine Clearance in Obtunded Blunt Trauma Patients: A Prospective Study

: An acceptable algorithm for clearance of the cervical spine (C-spine) in the obtunded trauma patient remains controversial. Undetected C-spine injuries of an unstable nature can have devastating consequences. This has led to reluctance toward C-spine clearance in these patients. : To objectify the accuracy of computed tomography (CT) scanning compared with dynamic radiographs within a well established C-spine clearance protocol in obtunded trauma patients at a level I trauma center. : This was a prospective study of consecutive blunt trauma patients (18 years or older) admitted to a single institution between December 2004 and April 2008. To be eligible for study inclusion, patients must have undergone both a CT scan and dynamic plain radiographs of their C-spine as a part of their clearance process. : Among 402 patients, there was one injury missed on CT but detected by dynamic radiographs. This resulted in a percentage of missed injury of 0.25%. Subsequent independent review of the CT scan revealed that in fact pathologic changes were present on the scan indicative of the injury. : Our results indicate that CT of the C-spine is highly sensitive in detecting the vast majority (99.75%) of clinically significant C-spine injuries. We recommend that CT be used as the sole modality to radiographically clear the C-spine in obtunded trauma patients and do not support the use of flexion-extension radiographs as an ancillary diagnostic method.

Are “Normal” Multidetector Computed Tomographic Scans Sufficient to Allow Collar Removal in the Trauma Patient?

Controversy continues as to the most safe and reliable method for clearing the cervical spine (C-spine) in a trauma patient who is rendered unable to participate in a clinical examination. Although magnetic resonance imaging (MRI) is the most sensitive test to detect soft-tissue injuries, it is impractical for routine use in every patient largely because of its cost and time of acquiescence. Recent studies have advocated the sole use of multidetector computed tomographic (MDCT) scans of the C-spine to decide if cervical collar immobilization can be discontinued. The current investigation retrospectively reviewed a series of MDCT scans obtained after an acute traumatic event that were used to direct treatment in the emergency department (ED) or intensive care unit. Seven-hundred and eight trauma patients consecutively admitted to the ED between June 2001 and July 2006 underwent a computed tomographic scan of their C-spine as part of an institutional protocol. We identified 91 patients with MDCT scans that were officially recorded as adequate and negative by an attending ED radiologist who had also undergone an MRI during the same trauma admission period. Retrospectively, two fellowship-trained spine surgeons independently reviewed these MDCT studies to address the following questions: (1) Is the study adequate? (2) Is it suggestive of an acute injury? (3) Is there sufficient information to safely recommend collar removal? Institutional Review Board approval was obtained before the images were reviewed. Neither clinical examination findings nor MRI readings were made available to the surgeon evaluators. Both spine surgeons agreed that 76 of the 91 studies (84%) were adequate to evaluate for possible C-spine injuries. Seven of 91 MDCT scans (8%) were deemed inadequate by both surgeons (95% confidence interval, 2.3-13.1). Reasons for inadequacy included motion artifact, insufficient visualization of the cervical-thoracic or occipital-cervical junctions, incomplete reconstructive views, or poor quality. Three of the adequate MDCT scans had fractures that were identified by both of the spine surgeons; 4 additional fractures and 15 findings suspicious for instability were identified by at least one of the surgeons. Ultimately, 22 of 91 MDCT scans read as adequate and normal by attending radiologists were deemed suspicious for abnormality by the spine surgeons. Of these 22 cases, the official MRI reading was positive for a trauma-related abnormality in 17 cases. C-spine clearance of patients without the ability participate in a clinical examination remains difficult. A multidisciplinary, algorithmic approach generally yields the most consistent results. However, our data highlight that reliance on a single imaging modality may lead to missed diagnosis of C-spine injuries. These data suggest that early involvement of the spine service for radiographic clearance may help identify occult injuries or suspicious findings necessitating further evaluation.

Clinical Examination in Complement With Computed Tomography Scan: An Effective Method for Identification of Cervical Spine Injury

The purpose of this study was to prospectively evaluate a protocol that assesses the efficacy and sensitivity of clinical examination in complement with computed tomographic (CT) scan in screening for cervical spine (c-spine) injury. During the 26-month period from March 2005 to May 2007, blunt trauma patients older than 13 years were prospectively entered into a study protocol. If patients were awake and alert with Glasgow Coma Score (GCS) >or=14, clinical examination of the neck was performed. Clinical examination was performed regardless of distracting injuries. If the patient had no complaints of pain or tenderness, the cervical collar was removed. Patients with complaints of c-spine pain or tenderness and patients with GCS score <14 underwent CT scanning for evaluation of the entire c-spine. One thousand six hundred eighty seven patients were prospectively assessed for blunt c-spine injury. Fourteen hundred thirty-nine patients had GCS score >or=14, 897 (62%) of which had a negative clinical examination of the c-spine and subsequently had cervical collars removed. Two patients (0.2%) whose clinical examination results disclosed nothing abnormal were later found to have a c-spine injury. Five hundred forty-two patients with GCS score >or=14 had a positive c-spine clinical examination, of which 134 (24%) were diagnosed with c-spine injury. One hundred thirty-three (99%) c-spine injuries were identified by CT scan. The c-spine injury missed by CT scan was a radiologic misinterpretation. For patients with c-spine injury with GCS score >or=14, both sensitivities of clinical examination and CT scan were 99%. Two hundred forty-eight patients had GCS score <14, of which 5 (2.0%) were diagnosed with c-spine injury. CT scan identified all c-spine injuries for patients with GCS score <14. In awake and alert blunt trauma patients, clinical examination is a sensitive screening method for c-spine injury. Clinical examination allows for the majority of blunt trauma patients to have their c-spines cleared safely without radiologic screening. Clinical examination in complement with CT scan is a sensitive and an effective method for identification of c-spine injury in awake and alert patients with symptoms of c-spine injury. CT scan is the sensitive and effective test for screening and diagnosis of c-spine injury in blunt trauma patients with altered mental status.

Is the Use of Pan-Computed Tomography for Blunt Trauma Justified? A Prospective Evaluation

Many trauma centers use the pan-computed tomography (CT) scan (head, neck, chest, and abdomen/pelvis) for the evaluation of blunt trauma. This prospective observational study was undertaken to determine whether a more selective approach could be justified. We evaluated injuries in blunt trauma victims receiving a pan-CT scan at a level I trauma center. The primary outcome was injury needing immediate intervention. Secondary outcome was any injury. The perceived need for each scan was independently recorded by the emergency medicine and trauma surgery service before patients went to CT. A scan was unsupported if at least one of the physicians deemed it unnecessary. Between July, 1, 2007, and December, 28, 2007, 284 blunt trauma patients (average Injury Severity Score = 11) underwent a pan-CT after the survey form was completed. A total of 311 CT scans were judged to be unnecessary in 143 patients (27%), including scans of the head (62), neck (50), chest (116), and abdomen/pelvis (83). Of the 284 patients, 48 (17%) had injuries on 52 unsupported CT scans. An immediate intervention was required in 2 of the 48 patients (4%). Injuries that would have been missed included 5 of 62 unsupported head scans (8%), 2 of 50 neck scans (4%), 33 of 116 chest scans (28%), and 12 of 83 abdominal scans (14%). These missed injuries represent 5 of the 61 patients with closed head injuries (8%) in the series, 2 of the 23 with C-spine injuries (9%), 33 of the 112 with chest injuries (29%), and 12 of the 86 with abdominal injuries (14%). In 19 patients, none of the four CT scans was supported; nine of these had an injury identified, and six were admitted to the hospital (1 to the intensive care unit). Injuries that would have been missed included intraventricular and intracerebral hemorrhage (4), subarachnoid hemorrhage (2), cerebral contusion (1), C1 fracture (1), spinous and transverse process fractures (3), vertebral fracture (6), lung lacerations (1), lung contusions (14), small pneumothoraces (7), grade II-III liver and splenic lacerations (6), and perinephric or mesenteric hematomas (2). In this small sample, physicians were willing to omit 27% of scans. If this was done, two injuries requiring immediate actions would have been missed initially, and other potentially important injuries would have been missed in 17% of patients.

Cervical Spine Motion

The optimal technique to intubate the trachea in patients presenting with a potential or documented cervical spine (C-spine) injury remains unresolved. Using continuous fluoroscopic video assessment, C-spine motion during laryngoscopy with an AirTraq Laryngoscope (King Medical Systems, Newark, DE) was compared to that with intubation using a Macintosh blade. Twenty-four healthy surgical patients gave written consent to participate in a crossover randomized controlled trial; all patients were subjected to both Macintosh and AirTraq laryngoscopy with manual inline stabilization after induction of anesthesia. The C-spine motion was examined at four areas: the occiput-C1 junction, C1-C2 junction, C2-C5 motion segment, and C5-thoracic motion segment. The time required for laryngoscopy was also measured. C-spine motion using the AirTraq was less than that during Macintosh laryngoscopy, averaging 66% less (P < 0.01) at three of the motion segments studied, occiput-C1, C2-C5, and C5-thoracic. There was no difference at the C1-C2 segment. There was no significant difference in the time to accomplish laryngoscopy between the two devices. For patients in whom C-spine movement is undesirable, use of the AirTraq Laryngoscope may be useful to limit movement without an increase in the duration of intubation.

From sidelined to inline. Be ready & equipped to treat athletic C-spine injuries in & on the field.

From sidelined to inline. Be ready & equipped to treat athletic C-spine injuries in & on the field.

Maxillofacial trauma patient: coping with the difficult airway

Establishing a secure airway in a trauma patient is one of the primary essentials of treatment. Any flaw in airway management may lead to grave morbidity and mortality. Maxillofacial trauma presents a complex problem with regard to the patient's airway. By definition, the injury compromises the patient's airway and it is, therefore, must be protected. In most cases, the patient undergoes surgery for maxillofacial trauma or for other, more severe, life-threatening injuries, and securing the airway is the first step in the introduction of general anaesthesia. In such patients, we anticipate difficult endotracheal intubation and, often, also difficult mask ventilation. In addition, the patient is usually regarded as having a "full stomach" and has not been cleared of a C-spine injury, which may complicate airway management furthermore. The time available to accomplish the task is short and the patient's condition may deteriorate rapidly. Both decision-making and performance are impaired in such circumstances. In this review, we discuss the complexity of the situation and present a treatment approach.

Canadian C-spine Rule and the National Emergency X-Radiography Utilization Low-Risk Criteria for C-spine radiography in young trauma patients

Purpose The Canadian C-spine (cervical spine) Rule (CCR) and the National Emergency X-Radiography Utilization Low-Risk Criteria (NLC) are criteria designed to guide C-spine radiography in trauma patients. It is unclear how these 2 rules compare with young children. Methods This study retrospectively examined case-matched trauma patients 10 years or younger. Two cohorts were identified—cohort A where C-spine imaging was performed and cohort B where no imaging was conducted. The CCR and NLC criteria were then applied retrospectively to each cohort. Results Cohort A contained 125 cases and cohort B with 250 cases. Seven patients (3%) had significant C-spine injuries. In cohort A, NLC criteria could be applied in 108 (86.4%) of 125 and CCR in 109 (87.2%) of 125. National Emergency X-Radiography Utilization Low-Risk Criteria suggested that 70 (58.3%) cases required C-spine imaging compared to 93 (76.2%) by CCR. National Emergency X-Radiography Utilization Low-Risk Criteria missed 3 C-spine injuries, and CCR missed one. In cohort B, NLC criteria could be applied in 132 (88%) of 150 and CCR in 131 (87.3%) of 150. The NLC criteria identified 8 cases and CCR identified 13 cases that would need C-spine radiographs. Fisher's 2-sided Exact test demonstrated that CCR and NLC predictions were significantly different ( P = .002) in both cohorts. The sensitivity of CCR was 86% and specificity was 94%, and the NLC had a sensitivity of 43% and a specificity of 96%. Conclusions Although CCR and NLC criteria may reduce the need for C-spine imaging in children 10 years and younger; they are not sensitive or specific enough to be used as currently designed.