clinical clearance of cervical spinal injuries by emergency nurses

342 C-SPINE CLEARANCE Hsieh et al. • CERVICAL SPINAL CLEARANCE BY NURSES

Clinical Clearance of Cervical Spinal Injuries byEmergency Nurses

MARGARET HSIEH, MD, MICHAEL GUTMAN, MD, PHD,DEBBIE HALISCAK, RN, EMT-P

Abstract. Objectives: To determine the interraterreliability between emergency nurses and emergencyphysicians on defined criteria for clinically clearingthe cervical spine in blunt trauma patients. Methods:

Blunt trauma patients, 12 years or older, arrivingwith cervical spinal precautions were prospectivelyenrolled as a convenience sample. Each member ofthe emergency physician–nurse pair completed aquestionnaire with regard to five criteria for clinicallyclearing the cervical spine for each patient. Interraterreliability was determined by calculating the k sta-tistics for the individual and combined criteria. Re-

sults: Physicians and nurses agreed on the presenceor absence of the combined criteria in 175 of 211 pa-tients (82.9%; k, 0.65). Agreements on individual cri-teria were as follows: 1) intoxication—203 patients(96.2%; k, 0.82); 2) altered consciousness—197 pa-tients (93.4%; k, 0.60); 3) neck pain—185 patients(87.7%; k, 0.75); 4) distracting injury—160 patients(75.8%; k, 0.36); and 5) neurologic deficit—198 pa-

tients (93.8%; k, 0.45). If disagreements in which thephysician would clinically clear the patient but thenurse would not were considered as agreements, thenoverall agreement would be 198 of 211 patients(93.8%; k, 0.88). On the assumption that nurseswould assess patients prior to physicians, they wouldhave cleared 35% of the patients before the physi-cians. However, they would have ordered 12% moreradiographs and unsafely clinically cleared 5% of thepatients. Conclusions: The interrater reliability forthe combined cervical spinal injury criteria betweenemergency nurses and physicians was good to excel-lent. However, with the training given in this study,nurses would order more radiographs than physi-cians and would unsafely clinically clear cervicalspines in some patients. Key words: cervical spine;spinal injury; cervical spine radiograph; trauma.ACADEMIC EMERGENCY MEDICINE 2000; 7:342–347

DESPITE the low incidence of cervical spinalinjuries,1–3 case reports of asymptomatic cer-

vical spinal injuries4–11 have contributed to the al-most universal application of cervical spinal pre-caution to blunt trauma patients. Other studieshave challenged the myth of painless cervical in-juries.2,12–21 These studies did not uncover painlessinjuries in alert, nonintoxicated, neurologically in-tact patients without distracting injuries. Jacobsand Schwartz found that physicians were notgood at predicting the presence of cervical injuriesbut they could reliably exclude injuries based ontheir histories and physical exams.22 The results of

From the Department of Traumatology and Emergency Medi-cine, University of Connecticut, Farmington, CT (MH, MG);Department of Emergency Medicine, Bristol Hospital, Bristol,CT (MG); and Department of Surgery, St. Francis Hospital,Hartford, CT (DH).Received June 17, 1999; revision received December 1, 1999;accepted December 6, 1999. Presented at the Northeast Re-gional Academic Emergency Medicine Research Symposium,New Haven, CT, April 1998; SAEM annual meeting, Chicago,IL, May 1998; and FAEM/SAEM Conference, Oxford, England,September 1998.Address for correspondence and reprints: Michael Gutman,MD, PhD, Department of Emergency Medicine, Bristol Hos-pital, PO Box 977, Brewster Road, Bristol CT 06010. Fax: 860-236-8217; e-mail: [email protected]

these studies suggest that cervical spinal injuriescould be clinically excluded in blunt trauma pa-tients reliably if the patients lack mental statuschange, evidence of intoxication, neck pain or ten-derness, neurologic deficit, and distracting inju-ries.14–16,19,21,23 Large, multicenter, prospective stud-ies are ongoing to validate these criteria. Despitethe results of these studies, a large number ofasymptomatic patients are subjected to the costand discomfort of cervical spinal immobilizationand radiography because of physicians’ fear ofmissing occult cervical spinal injuries.

Mahadevan et al.24 stated that such criteriawould be of limited usefulness if health care pro-viders could not apply them consistently to thesame patients. Their study demonstrated high in-terrater reliability among emergency physicians(EPs) for the application of risk criteria similar tothose used in previous studies14–16,19,21,23 for clini-cally clearing cervical spinal injuries. However,few studies have evaluated the interrater reliabil-ity in the use of these criteria by other health careworkers. Sahni et al. reported that paramedicscould reliably apply these criteria to simulated pa-tients25; however, subsequent studies have showninconsistent interobserver agreements between

ACADEMIC EMERGENCY MEDICINE • April 2000, Volume 7, Number 4 343

out-of-hospital personnel and EPs.26,27 To ourknowledge, no work has yet been reported onemergency nurses’ ability to use these criteria.

In a busy ED, patients suffering from low-ve-locity trauma or injuries from mechanisms that donot meet American College of Surgeons (ACS) cri-teria for transport to trauma centers28 may oftenbe immobilized for a prolonged time before physi-cian evaluation. For a patient without spinal in-jury, this wait prolongs the discomfort and risks ofimmobilization.29–32 In EDs where nurses oftenoutnumber the EPs and do initial patient assess-ments, the wait and discomfort could potentiallybe diminished if emergency nurses could reliablyapply the criteria used by the physicians for clini-cal clearance of the cervical spine. However, theability of nurses to apply the criteria in a mannersimilar to that of the physicians must be assessedbefore allowing them to clear cervical spinal inju-ries clinically. Thus, the objective of this study wasto determine the interrater reliability betweenemergency nurses and physicians in the applica-tion of cervical spinal clearance criteria.

METHODS

Study Design. This was a prospective study of aconvenience sample of blunt trauma patients withcervical spinal precautions on arrival to the ED.Physicians and nurses completed questionnairesregarding the absence or presence of criteria forclinically clearing the cervical spine of each en-rolled patient. The results were then compared.The Institutional Review Board of St. Francis Hos-pital and Medical Center, a medical school andemergency medicine (EM) residency-affiliated in-stitution, approved this study.

Study Setting and Population. Blunt traumapatients were prospectively enrolled at this urbanED from June 1997 to July 1998. Patients aged 12years or older arriving to the ED on a long boardand with a cervical collar in place were included ifthey had sustained blunt trauma of any severity,ranging from low-speed motor vehicle collisionsand falls from standing position to multipletrauma necessitating resuscitative measures. Pa-tients younger than age 12 and those who had sus-tained neck injury more than 24 hours before pre-sentation to the ED were excluded. Patients wereenrolled as a convenience sample when nurses andphysicians on duty remembered to complete thequestionnaires, and when the department was notoverwhelmed with a large volume of patients.Some nurses were more motivated than others andenrolled more patients. Therefore, it cannot be saidwith confidence that consecutive patients were en-rolled.

Study Protocol. Prior to being allowed to partic-ipate, ED nurses underwent a brief cervical spinalclearance training by reading an educational pam-phlet (Fig. 1), which served as the only instructionto the definitions of the criteria and physical ex-amination. There was no physical demonstrationof the examination during training. Nurses wererequired to answer correctly all the questions of abrief written exam consisting of patient scenarios.The training sessions took about 15 minutes in to-tal to complete. Unlike the nurses, the physiciansdid not go through any specific training with re-gard to cervical spinal clearance but generally ad-hered to the hospital group’s practice of clinicallyclearing the cervical spine based on the criterialisted in the questionnaire. Patients without thesecriteria had their cervical spines clinically clearedif they had no discomfort with or limitation to therange of motion of their necks.

The nurses in this department had varying de-grees of nursing experience, ranging from twomonths to more than 20 years in EM. All nurseshad a minimum of six weeks’ orientation to the EDand trauma nursing certification training beforebeing allowed to function independently in thetrauma room of the ED. Physician participantswere full-time, board-certified EPs with experienceranging from 2 to 15 years in EM.

Out-of-hospital workers were instructed bywritten protocol to apply cervical spinal precau-tions (stiff neck collar and long hardboard) to pa-tients with the following conditions: any blunt in-jury above the clavicle, unconsciousness, multipletrauma, high-speed crash, neck pain, and/or com-plaints of extremity numbness/tingling. In reality,in this emergency medical services system, almostany blunt trauma, including falls and low speed-motor vehicle collisions, would result in patienttransport to the ED in full cervical spinal precau-tions. Written protocols for clearing the cervicalspine in the ED at the time of this study directednurses to inform the physicians on duty of the ar-rival of a patient with cervical spinal precautionsas soon as possible.

Each member of the EP–nurse pair completeda questionnaire (Fig. 2) asking about the five cer-vical spinal clearance criteria and the overall needof a cervical spinal radiograph for each patient,prior to any x-rays’ being ordered. Although the im-plications of the two last questions in Figure 2were redundant, both questions were included toensure that the respondent understood that re-moval of a collar was equivalent to clinically clear-ing the cervical spine. The nurses and physiciansdeposited their completed questionnaires at sepa-rate locations. As this was a very busy and physi-cally large ED, a nurse and then a physician ex-amined the patients at separate times for most


cases. The nurses were instructed not to discusstheir findings with the physicians until both hadcompleted their examinations. No independent ob-

How to Clinically Clear the Cervical Spine

Clearing the cervical spine clinically means being able toconfirm that there are no fractures or instability without theuse of x-rays. Clearing the cervical spine clinically involvesevaluating the patient on four components: 1) an alteredlevel of consciousness or drug or alcohol ingestion, 2) lackof pain or posterior cervical spine tenderness, 3) no dis-tracting injuries, and 4) no new onset of focal neurologicdeficit.

1. Altered Level of Consciousnessl If a patient appears to be intoxicated, admits to re-

cent alcohol or drug ingestion, the cervical spinecannot be cleared clinically.

l If the patient has a GCS less than 15 (15 = orientedX3, eyes open, and moving all limbs to command),the cervical spine cannot be cleared.

2. Painl If the patient complains of posterior neck pain, the

cervical spine cannot be cleared.l If the patient is tender to palpation of the posterior

aspect of the neck, defined as the region behind theline extending vertically from the ears down, thecer-vical spine cannot be cleared.

3. Distracting InjuryThere is no definitive answer to what constitutes adistracting injury. If the patient is able to tell you thatthe examiner is pinching the back of his or her neckin a painful but noninjurious way, then he or she isprobably not distracted.l If the patient has a distracting injury causing a

great deal of pain, the cervical spine cannot becleared.

4. Neurologic Deficitl If the patient is complaining of new-onset weakness

or numbness in one or more of the limbs, the cer-vical spine cannot be cleared.

l A weak limb can be defined as asymmetric handgrip strength, one of the arms drifting when they areboth raised at once, or inability to lift the limb whenin a supine position. Altered sensation in a limb isany subjective complaint by the patient or findingsof numbness or diminished tactile sense in one ormore limbs. If upon examining the patient it is foundthat one or more of the limbs appears weaker or hasaltered sensation, the cervical spine cannot becleared.

5. The Four ComponentsThe patient must be evaluated on all four componentsbefore the cervical spine can be cleared. If any oneof the four components is present, the cervicalspinecannot be cleared.

Figure 1. Instructions to participating nurses.

server was present to ensure the standardizationor independence of examinations. This study wasnot attempting to verify the safety of the clinicalcriteria used for clearing the cervical spine; no fol-low-up was performed on any of the patients.

Data Analysis. Interobserver reliability for thecombined criteria and for each individual criterionwas calculated using the kappa statistics,33 and de-scribed with 95% confidence intervals (CIs).

RESULTS

A total of 211 survey pairs were collected duringthe study period. There were 99 men and 112women in this study group. The ages of the pa-tients ranged between 14 and 103 years, with amean age of 40.7 6 22.4 (SD).

Table 1 lists the kappa statistics and CIs for theindividual criterion and for the combined criteria.The table also includes the above statistics for ‘‘cor-rected’’ disagreements. These were cases where thephysician would clinically clear the patient, butthe nurse would not. These cases were changed(corrected) into agreements; assuming that EPsare more adept at applying these criteria, thesedisagreements were considered as clinically safe,as opposed to unsafe disagreements, in which thenurse would have clinically cleared the patient butthe physician would obtain a radiograph first. Theinterrater reliability of an individual criterionranged from a low of 0.36 (distracting injuries) toa high of 0.82 (presence of drugs or alcohol) in theuncorrected set and from 0.74 (distracting injuries)to 0.88 (presence of drugs or alcohol) in the cor-rected set. The nurses would have cleared the cer-vical spine clinically 18 times, and the physicianswould have cleared the cervical spine clinically 14times (Table 2) despite the presence of at least onecriterion that would have precluded them from do-ing so according to the guidelines. Table 2 showsthat the most commonly ignored criterion by bothnurses and EPs was the presence of distracting in-jury. The physicians would not clinically clear twopatients and the nurses would not clear three, de-spite the absence of all criteria for those patients.

The physician–nurse pairs disagreed 36 timesin this study of 211 patients. On the whole, thenurses would have clinically cleared cervicalspines less often than would the physicians. Thissituation was reflected by the fact that 25 of the36 disagreements were clinically safer disagree-ments. These clinically safer disagreements wouldtranslate to the nurses’ ordering almost 12% morecervical spinal x-rays than the physicians. Fur-thermore, there were 11 (5% of 211) unsafe dis-agreements. The most common reasons for unsafedisagreements were the presence of neck pain and


Is there a suspicion of drug or alcoholintake? Yes No

Is there altered consciousness? Yes NoIs there neck pain or tenderness in the

posterior aspect of the neck (definedas the area behind the line extendingvertically from the ears down)? Yes No

Is there distracting injury or pain? Yes NoIf yes, what?Is there new onset of numbness or

weakness since the injury? Yes NoDoes this patient need a hard collar? Yes NoDoes this patient need an x-ray for his

or her c-spine? Yes No

Figure 2. Questionnaire for physicians and nurses.

TABLE 1. Interrater Reliability of Cervical Spinal Injury Criteria in 211 Patients with Blunt Trauma

Criterion

Number of Cases with Agreement(Kappa*, 95% Confidence Interval)

Uncorrected† Corrected‡

Presence of drugs or alcohol 203 (0.82, 0.71, 0.94) 206 (0.88, 0.79, 0.98)Altered level of consciousness 197 (0.60, 0.40, 0.80) 204 (0.77, 0.60, 0.95)Presence of neck pain or tenderness 185 (0.75, 0.66, 0.84) 197 (0.86, 0.80, 0.93)Presence of distracting injuries 160 (0.36, 0.22, 0.49) 198 (0.77, 0.65, 0.90)Presence of neurologic deficit 198 (0.45, 0.20, 0.70) 207 (0.74, 0.50, 0.98)Clinical clearance of cervical spine 175 (0.65, 0.55, 0.76) 198 (0.88, 0.81, 0.94)

*Kappa of <0.4 = poor agreement, 0.4–0.6 = fair agreement, 0.6–0.8 = good agreement, and >0.8 = excellent agreement.†Uncorrected = original responses of the physicians and nurses.‡Corrected: included clinically safer disagreements in which nurses would not clear the cervical spine clinically but physicianswould.

the presence of distracting injury, even though thekappa statistic suggested good to excellent agree-ment in the corrected set.

Of the 211 patients, there were two known spi-nal fractures, a C2 hangman’s fracture, and a C5compression fracture. Both patients suffered frommechanisms of injury that warranted assessmentand resuscitation by the hospital trauma team,which included the EP and nurses. The nurses andphysicians in these cases agreed with each other;however, they worked in close proximity in thesecases during their assessments. There was noknown patient who would have been clinicallycleared by the nurse and then subsequently foundto have a cervical spinal fracture.

DISCUSSION

In our study, good interrater agreement was foundbetween the ED nurses and physicians for the com-bined criteria for clinically clearing cervical spinesin blunt trauma patients. The concordance im-proved into the excellent range by considering clin-ically safer disagreements as agreements. An in-dividual criterion did not perform as well as thecombined criteria; in the original responses, the re-liabilities ranged from poor to good. Distracting in-juries, presence of pain or tenderness, and neuro-logic deficits were the most disputed criteria.Despite having the definition of each criterion out-lined in the pre-participation educational material,providers appeared to have different opinions re-garding what constituted a positive criterion. Ingeneral, nurses appeared to be more conservativein their definitions (i.e., considering minor extrem-ity contusions or strains as distracting injuries) asevidenced by the fact that the scores for distractinginjuries and neurologic deficits improved substan-tially by considering clinically safer disagreementsas agreements.

If nurses had been allowed to clear the patientsin this study, 74 (35.1%) patients could have hadtheir cervical spinal immobilization removed prior

to physician evaluation, since they lacked all of therisk criteria as judged by both the nurse and thephysician. On the other hand, the nurses wouldhave ordered 12% more cervical x-rays than thephysicians. This potential increase in cost could bereduced by using a two-tiered evaluation system,in which the physicians would further evaluatethose patients whom nurses did not clear prior toordering cervical spinal radiographs. Extrapolat-ing from the data in this study, nursing clinicalclearance would miss 6.25 more cervical spinal in-juries per hundred thousand trauma patients un-dergoing cervical radiography than physicianclearance (calculated by multiplying clinically un-safe disagreement rate of 5% by the incidence ofcervical spinal fractures of 125/100,000 trauma pa-tients undergoing cervical radiography34,35). Thesedata suggest that the higher cost of extra radio-graphs and the potential of an increased numberof missed injuries using nursing clearance withoutphysician supervision would have offset the poten-tial benefits of more prompt removal of cervicalspinal precaution in a third of the study patients.

In our study, physician examination is used asa basis (criterion standard) for comparison fornursing evaluation, since physicians traditionally


TABLE 2. Patients Whose Cervical Spines Would Have BeenCleared Clinically Despite Presence of Criteria againstDoing So

Criterion Physician Nurse

Presence of drugs or alcohol 4 2Altered level of consciousness 0 2Presence of neck pain or tenderness 4 0Presence of distracting injuries 6 13Presence of neurologic deficit 0 1

TOTAL 14 18

make the clinical judgment regarding cervical spi-nal clearance, and therefore have more experienceusing the criteria. This study does not attempt toevaluate the safety of the criteria used or the abil-ity of physicians to apply them correctly and con-sistently.

This study is the first step toward assessing thefeasibility of clinical cervical spine clearance bynurses. It was designed to evaluate only whethernurses could agree with physicians on clinicallyclearing the cervical spine, but not the cost–effec-tiveness or the expeditiousness of nursing clear-ance. In the ED in which this study was done,nurses were more likely to assess the patientsprior to physician evaluation, since the nurse–phy-sician ratio ranged from 2:1 to 4:1 depending onthe time of day. Almost invariably, nurses did ini-tial patient assessments, except in critically illcases. However, the likelihood of nurses’ seeing thepatient first, as in this study, cannot necessarily begeneralized to all EDs. Furthermore, no data werecollected on the interval between the nurse andphysician assessment; therefore, no conclusion canbe drawn regarding whether the ability of thenurse to clinically clear cervical spines would ex-pedite this process.

LIMITATIONS AND FUTURE QUESTIONS

The use of convenience sampling may have sub-jected this study to patient selection bias. Nursesand physicians may be less likely to complete thequestionnaire during busier times in the ED.There is no reason to assume that the patients pre-senting during busier times are pathophysiologi-cally different from those presenting during slowertimes. However, providers may have less time toevaluate the patient as thoroughly at busy times,thereby affecting their determination of the pres-ence of the risk criteria. They may also be lesslikely to complete the questionnaire for patientswith more severe injuries or mechanisms of injury,due to the need to expedite patient evaluation andstabilization. These patients, however, are morelikely to have clear presence of one of the criteria.

The fact that some nurses were more motivatedthan others to enroll patients may have skewedthe data as well. Nurses who are more motivatedto enroll patients may be better at their clinicalassessment skills than other nurses, as they maydo more of these assessments. Alternatively,nurses who were less adept at assessing patientsbut filled out more questionnaires may have pro-duced a greater degree of disagreement.

The delay between nurse and physician evalu-ations may have confounded the responses, be-cause a patient’s condition may have changed be-tween the two examinations. While asymptomaticinitially, patients may develop pain from the im-mobilization while waiting for the physician eval-uation. This could result in an opinion of clinicalclearance by the nurse, but not by the physician,and therefore cause a clinically unsafe disagree-ment. We did not measure the time between eval-uations in this study. This question could be ad-dressed in a future study. Mahadevan et al.’sresults,24 however, suggested that the delay be-tween examinations did not adversely affect inter-rater reliability in their study.

The department layout and the logistics of pa-tient care in this ED were conducive to indepen-dent nursing and physician evaluations. The vol-ume of patients precluded physician presenceduring the initial nursing assessment. However,there was no independent viewer in this study toensure that nursing examinations were done outof earshot or view of the physician and that suchdiscussions did not take place. As a result it cannotbe said with complete certainty that the physiciansand nurses did not influence each other’s assess-ments.

Substantial disagreements on the definitions ofeach criterion appeared to exist despite an attemptto clarify these definitions in the pre-participationpamphlets. These disagreements may continue toexist even among physicians since words such aspain, distraction, or numbness are highly subjec-tive. Recent alcohol or drug ingestion referred toin item 1 of Figure 1 was not operationally definedbut rather left to the examiner, as is the currentreality of patient care. No good data exist to sug-gest what time interval from last alcohol ingestionor what blood alcohol level is safe for allowing clin-ical clearance of the cervical spine. Similarly, thereis no evidence to guide what drug (illicit or pre-scribed), what quantity, or what interval from timeof ingestion is safe for allowing clinical clearanceof the cervical spine.

There was no assurance that the physical examwas complete and appropriate on either the nurses’or physicians’ part. This variability in examinationmay continue to exist even after a vigorous defi-nition and evaluation of the examination method


because clinicians may not always be able to useadditional measurement devices or rules in a busysetting. A reproducible definition of distracting in-jury remains to be defined by evidence in the lit-erature. More rigorous definitions of the criteriaand extensive training may improve agreementsbetween nurses and physicians, and warrant fu-ture studies.

CONCLUSIONS

Emergency nurses and physicians demonstratedgood agreement on clinically clearing the cervicalspine using criteria that are presently being vali-dated in other studies. However, nurses still wouldhave cleared some patients who may have had in-juries. If nurses had been allowed to order cervicalspinal radiographs based on their use of these cri-teria, they would have ordered more x-rays thanwould the EPs. Nurses with the amount of traininggiven in this study would clear cervical spines lesssafely and less-cost effectively than would EPs.

Thanks to Jeff Mathers for his statistical support and to A. J.Smally, MD, for his help in preparation of the manuscript.

References

1. Hu R, Mustard CA, Burns C. Epidemiology of incident spi-nal fracture in a complete population. Spine. 1996; 21:492–9.2. Lindsey RW, Diliberti TC, Doherty BJ, Watson AB. Efficacyof radiographic evaluation of the cervical spine in emergencysituations. South Med J. 1993; 86:1253–5.3. Davis JW, Phreaner DL, Hoyt DB, Mackersie RC. The eti-ology of missed cervical spine injuries. J Trauma. 1993; 34:342–6.4. Austin P, Hanlon D. Unrecognized pathologic fractures ofthe cervical spine: two case reports and review of the litera-ture. J Emerg Med. 1993; 1:409–13.5. McKee TR, Tinkoff G, Rhodes M. Asymptomatic occult cer-vical spine fracture: case report and review of the literature. JTrauma. 1990; 30:623–6.6. Bohlman HH. Acute fractures and dislocations of the cer-vical spine. J Bone Joint Surg. 1979; 61A:1119–42.7. Ogden W, Dunn JD. Cervical radiographic evaluation fol-lowing blunt trauma. Ann Emerg Med. 1986; 15:604–5.8. Thambyrajah K. Fractures of the cervical spine with mini-mal or no symptoms. Med J Malaysia. 1972; 26:244–9.9. Maull KI, Sachatello CR. Avoiding a pitfall in resuscitation:the painless cervical fracture. South Med J. 1977; 70:477–8.10. Bresler MJ, Rich GH. Occult cervical spine fracture in anambulatory patient. Ann Emerg Med. 1982; 11:440–2.11. Haines JD. Occult cervical spine fractures. Postgrad Med.1986; 80:73–7.12. Sweeney TA, Marx JA. Blunt neck injury. Emerg Med ClinNorth Am. 1993; 11:71–9.

13. Velmahos GC, Theodorous D, Tatevossian R, et al. Radio-graphic cervical spine evaluation in the alert asymptomaticblunt trauma victim: much ado about nothing? J Trauma.1996; 40:768–74.14. Hoffman JR, Schriger DL, Mower W, Luo JS, Zucker M.Low-risk criteria for cervical spine radiography in blunttrauma: a prospective study. Ann Emerg Med. 1992; 21:1454–60.15. Ringenberg BJ, Fisher AK, Urdaneta LF, Midthun MA.Rational ordering of cervical spine radiographs followingtrauma. Ann Emerg Med. 1988; 17:792–6.16. Roberge RJ, Wears RC, Kelly M, et al. Selective applica-tion of cervical spine radiography in alert victims of blunttrauma: a prospective study. J Trauma 1988; 28:784–8.17. Kreipke DL, Gillespie KR, McCarthy MC, Mail JT, LappasJC, Broadie TA. Reliability of indications for cervical spinefilms in trauma patients. J Trauma. 1989; 29:1438–9.18. McNamara RM, Heine E, Espositio B. Cervical spine in-jury and radiography in alert, high-risk patients. J EmergMed. 1990; 8:177–82.19. Bachulis BL, Long WB, Hynes GD, Johnson MC. Clinicalindications for cervical spine radiographs in the traumatizedpatient. Am J Surg. 1987; 153:473–7.20. Bayless P, Ray VG. Incidence of cervical spine injuries inassociation with blunt head trauma. Am J Emerg Med. 1989;7:139–42.21. Fischer RP. Cervical radiographic evaluation of alert pa-tients following blunt trauma. Ann Emerg Med. 1984; 13:905–7.22. Jacobs LM, Schwartz R. Prospective analysis of acute cer-vical spine injury: a methodology to predict injury. Ann EmergMed. 1986; 15:44–9.23. Hoffman JR, Mower WR. When to image cervical spineinjuries [letter]. West J Med. 1991; 155:290.24. Mahadevan S, Mower WR, Hoffman JR, Peeples N, Gold-berg W, Sonner R. Interrater reliability of cervical spine injurycriteria in patients with blunt trauma. Ann Emerg Med. 1998;31:197–201.25. Sahni R, Menegazzi JJ, Mosesso VN Jr. Paramedic eval-uation of clinical indicators of cervical spinal injury. PrehospEmerg Care. 1997; 1:16–8.26. Brown LH, Gough JE, Simonds WB. Can EMS providersadequately assess trauma patients for cervical spinal injury?Prehosp Emerg Care. 1998; 2:33–6.27. Meldon SW. Out-of-hospital cervical spine clearance.Agreement between emergency medical technicians and emer-gency physicians. J Trauma. 1998; 6:1058–61.28. Eastman AB. Resources for the optimal care of the injuredpatient. Bull Am Coll Surg. 1994; 79(5):21–7.29. Chan D, Goldberg R, Tascone A, Harmon S, Chan L. Theeffect of spinal immobilization on healthy volunteers. AnnEmerg Med. 1994; 23:48–51.30. Cordell WH, Hollingsworth JC, Olinger ML, Stroman SJ,Nelson DR. Pain and tissue-interface pressures during spine-board immobilization. Ann Emerg Med. 1995; 26:31–6.31. Schafermeyer RW, Ribbeck BM, Gaskin J, et al. Respira-tory effects of spinal immobilization in children. Ann EmergMed. 1991; 20:1017–9.32. Walsh M, Grant T, Mickey S. Lung function compromisedby spinal immobilization [letter]. Ann Emerg Med. 1990; 19:615–6.33. Fleiss JL. Statistical Methods for Rates and Proportions.2nd Ed. New York: J Wiley & Sons, 1981, pp 217–32.34. Meyer PR. New focus on spinal cord injury. JAMA. 1981;245:1201–6.35. Green BA, Callahan RA, Klose KJ, et al. Acute spinal cordinjury: current concepts. Clin Orthop. 1981; 154:125–35.

clinical clearance of cervical spinal injuries by emergency nurses

Documents