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Evidence in the ED C-spine Rules

Evidence in the ED C-spine Rules. Angela M. Mills, MD September 3, 2002. NEXUS 5 Criteria. No midline cervical tenderness No focal neurologic deficit Normal level of alertness No intoxication No painful, distracting injury. Hoffman: NEJM, Vol 343(2). July 13, 2000. 94-99. NEXUS trial.

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Evidence in the ED C-spine Rules

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  1. Evidence in the EDC-spine Rules Angela M. Mills, MD September 3, 2002

  2. NEXUS 5 Criteria • No midline cervical tenderness • No focal neurologic deficit • Normal level of alertness • No intoxication • No painful, distracting injury Hoffman: NEJM, Vol 343(2). July 13, 2000. 94-99

  3. NEXUS trial • Prospective, observational study at 21 centers • 34,069 patients with blunt trauma who underwent radiography of cervical spine • Low probability of c-spine injury if patients met all 5 clinical criteria and were clinically stable Hoffman: NEJM, Vol 343(2). July 13, 2000. 94-99

  4. Results • 818 (2.4%) radiographically documented cervical-spine injuries • Missed 8 of 818 injuries • Only 2 of 8 missed met criteria for clinically significant injury Hoffman: NEJM, Vol 343(2). July 13, 2000. 94-99

  5. Injuries which require no specific treatment Injuries which would result in no harm if not identified Spinous-process fracture Simple wedge-compression fx w/o loss of 25% or more of height Isolated avulsion w/o lig injury End-plate fracture Osteophyte fx, not including corner fx or teardrop fx Injury to trabecular bone Transverse-process fracture Not clinically significant injuries Hoffman: NEJM, Vol 343(2). July 13, 2000. 94-99

  6. Results • Sensitivity 99.0 % • Negative Predictive Value 99.8 % • Specificity 12.9 % • Positive Predictive Value 2.7 % All Patients Hoffman: NEJM, Vol 343(2). July 13, 2000. 94-99

  7. Results • Sensitivity 99.6 % • Negative Predictive Value 99.9 % • Specificity 12.9 % • Positive Predictive Value 1.9 % Patients with clinically significant injuries Hoffman: NEJM, Vol 343(2). July 13, 2000. 94-99

  8. NEXUS trial • Able to identify patients, with high degree of confidence, with blunt trauma with extremely low probability of injury to cervical spine • Limited number of criteria easy to remember • Overall miss rate less than 1 in 4,000 patients • Sensitivity approaches 100% for clinically important injuries Hoffman: NEJM, Vol 343(2). July 13, 2000. 94-99

  9. HUP ism • Large study that shows that what most are people were already doing was correct • A reasonable approach to C-spine radiography

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