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C-spine Clearance in an Unreliable Patient (Cincinnati Children’s)

2.0 DEFINITIONS


2.1. Unreliable Exam: A patient who meets any of the following criteria cannot undergo clinical clearance of the
cervical spine:
—2.1.1. Verbal GCS≤4
—2.1.2. Intubated patient
—2.1.3. ETOH/Drug intoxication
2.2. Clinical clearance of the cervical spine may be performed if ALL of the following criteria are present: 2.2.1. Normal neurologic exam; and
—2.2.2. No tenderness to palpation of the cervical spine; and
—2.2.3. No cervical spine pain with active range of motion; and
—2.2.4. No distracting injuries


3.0 GUIDELINE


3.1. Complete primary and secondary surveys per CCHMC guidelines 3.2. If patient is found to be unreliable:
3.2.1. Cervical collar should be placed
3.2.2. C-spine radiographs should be obtained in the ED (minimum: cross table/lateral) 3.3. Cervical spine radiographs are abnormal:
3.3.1. Maintain cervical collar 3.3.2. Obtain neurosurgical consult 3.3.3. Treatment as indicated
3.4. Cervical spine radiographs are normal, and: 3.4.1. Reliable exam
—a. Exit pathway; refer to reliable c-spine algorithm 3.4.2. Remains unreliable
—a. Maintain cervical collar
—b. Consider CT cervical spine (skull base through T1) within 24 hours 3.5. Cervical CT abnormal:
3.5.1. Maintain cervical collar 3.5.2. Obtain neurosurgical consult 3.5.3. Treatment as indicated
3.6. Cervical spine CT normal: 3.6.1. Patient now reliable
—a. Exit pathway
—b. Refer to reliable c-spine algorithm 3.6.2. Patient remains unreliable:
—a. Maintain cervical collar
—b. MRI cervical spine within 72 hours when stable for transport 3.7. Cervical spine MRI normal:
3.7.1. Document radiographic findings
3.7.2. Remove cervical collar 3.8. Cervical spine MRI abnormal:
3.8.1. Maintain cervical collar 3.8.2. Obtain neurosurgical consult 3.8.3. Treatment as indicated

4.0 REFERENCES


4.1. American College of Surgeons Committee on Trauma. (2012). Spine and spinal cord trauma. In Advanced trauma life support: Student course manual,(9th ed. (p. 185-189). Chicago: Il.
4.2. Como, JJ, Diaz, JJ, Dunham, CM, Chiu, WC, Duane, TM, Capella, JM, Holevar, MR, Khwaja, KA, Mayglothing, JA, Sharior, MB, & Winston, ES. (2009). EAST guideline: Identification of cervical spine injuries. Journal of Trauma, 67(3), 651-59.
4.3. Rozzelle, CJ, Arabi, B, Dhali, SS, Gelb, DE, Hurlbert, RJ, Ryken, TC, Theodore, N, Walters, BC, & Hadley, MN. (2013). Management of pediatric cervical spine and spinal cord injuries. Neurosurgery supplement, 72(3), 205- 226.
4.4. Ryken, TC, Hadley, MN, Walters, BC, Aarabi, B, Dhali, SS, Gelb, DE, Hurlbert, RJ, Rozzelle, CJ, & Theodore, N. (2013). Radiographic assessment. Neurosurgery supplement, 72(3), 54-72.

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