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


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


3.1. 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


4.1. 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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