In this micro-lecture, we discuss C Spine Clearance and in particular the Nexus Criteria which has allowed Paramedics to safely undertake an assessment of a patient in relation to their spinal injuries. Enrolled students have unlimited access to a rich library of learning materials such as this.
In today’s micro lecture, we’re going to talk about C-spine clearance. Now, C-spine clearance is a very interesting subject because historically, as the paramedic profession in its earlier days, the paramedics were never really allowed to clear the C-spine because it came with quite some significant high risks, this high stakes, high risks, particularly if the paramedics got it wrong. In those days, during those times, paramedics were basically immobilising anybody where there was a consideration of C-spine, which very much relied upon the paramedic’s clinical judgment.
Now, the good news is, more recently there was a large research study done called the NEXUS study, which is what we’re going talk about here, which now is enforced in pretty much quite a few … I’m going to avoid saying all ambulance services, but it’s a very reliable study, which now allows paramedics to be able to safely clear someone’s C-spine.
Now, when we say, “Clear,” what we mean is be able to undertake an assessment of these points here on the screen to be able to determine if you’re going to have to do a full spinal immobilization or if you can actually get them up and walking to the ambulance.
The NEXUS criteria pivots around five key criteria. Number one, midline cervical tenderness. Number two, altered mental status. Number three, focal neurological deficit. Number four, evidence of intoxication. And the fifth one, painful distracting injury. Let’s look through these together then.
Imagine this: You’ve arrived on scene and there’s a car that looks like it’s pretty badly damaged, and there’s somebody sitting in the passenger seat, rubbing their neck saying, “Oh, I’ve got some neck pain.” Well, then you go, “That would fall into midline cervical tenderness.” Now, let’s focus in on the word midline, because as you know, the midline is drawing an imaginary line down the middle, thus midline. It’s this pain off to the left, off to the right. That’s excluded.
Now here, it says, “The midline cervical tenderness is present if the pain is elicited on palpation of the posterior cervical midline from the nuchal ridge to the prominence of the first thoracic vertebrae or if pain is reported on palpation of any cervical spinal process.” These are all middle. These are all the middle. In other words, when you press down in the middle and then the patient says, “Ow,” then maybe they are indicating. Altered mental status, or if somebody has a GCS below 14, they’re a little bit confused, they can’t remember three objects in a five-minute period of time, or they’ve got an inappropriate response to external stimulation.
Focus neurological deficit. If you as the paramedic says, “Can you feel me touching here?” Get the patient to close their eyes and say, “Can you feel me touching,” and you tap their left leg, that’s the focal neurological deficit. Or, if the patient says to you, “I can’t feel my legs,” that’s another one. Evidence of intoxication. This includes recent history reported by the patient or the observer of intoxication. Evidence of intoxication on physical exam, in other words, you can smell the alcohol on someone’s breath, they’ve got slurred speech, behavior consistent with intoxication, people who are combative, reduced CGS, those types of things. I’m sure you all know what that looks and sounds like.
Test of bodily secretions are positive to certain drugs. Now, we can’t do this pre-[hospitally 00:03:24], so that excludes us. Painful distracting injury. You arrive on scene and somebody’s saying, “Ow, my leg, my leg. Help, I’m in a lot of pain.” Any conditioned thought by the clinician to be producing pain sufficient to distract them away from the C-spine injury, and there’s some great examples here. Any long bone fractures, significant visceral pain, large laceration, extensive burns, and anything else. In summary, that’s the NEXUS criteria and you can access this document on the Royal Australian College of GP’s website at any time.