Canadian C-Spine Rule (CCR)

The Canadian C-Spine Rule was created in response to increased costs associated with non-essential radiography (98%) and increased patient wait times while immobilized to back boards. This month’s article will review the research and findings associated with the Canadian C-Spine Rule (CCR) and relate them to EMS practices.

Currently paramedic schools in Ontario teach C-spine to be ruled out in every call. Rather than having C-spine ruled out C-spine should be a protocol that is ruled in, not only through indications and contraindications but common sense as well. It is understandable that with a cervical spine injury you want to perform manual stabilization as soon as possible, but without a suggestive mechanism of injury when you introduce yourself to the patient it is not necessary to hold a patient’s head while you check their neck, especially if their complaint is unrelated.

In one study CCR has been found correct in 99.7% of cases. This indicates 1 error in 313 patients. Another study including 12 hospitals the CCR correctly identified all clinically important cervical spine fractures and of those ruled out none had shown fractures or adverse outcomes upon study follow-up. The CCR has shown great success in hospitals and has reduced patient wait times with collars and rigid back boards, as well as decreased associated radiography costs.

The next step in the process should extend the CCR to EMS, the personnel that find patients and are most likely to determine the severity of the mechanism among other signs indicating true cervical spine injuries. Ambulance use of CCR would decrease time and resources spent non-essentially. Also it would prevent negative effects from backboards, such as: increase head, neck and back pain; claustrophobia or agitation; risk of aspiration; and decubitus ulcers.

A study that proposed nurses using CCR concluded that the only cases missed were where the nurses overlooked one or more of the criteria present on the CCR, but otherwise was successful. This indicated an ability to clear resuscitation rooms early and provide for patients requiring more immediate and detrimental attention. If this occurred on scene a decrease in resources would occur from patient contact in ambulance services through to the patient’s exit from the hospital.

All evidence reviewed here leaves one question unanswered, why have base hospital physicians not implemented CCR for paramedics in Ontario?

To see the articles referenced above you can follow these links:
Implementation of the Canadian C-Spine Rule: prospective 12 centre cluster randomised trial
The Canadian C-Spine Rule versus the NEXUS Low-Rick Criteria in Patients with Trauma 
Multicentre prospective validation of the use of the Canadian C-Spine Rule by triage nurses in the emergency department

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2 Responses to Canadian C-Spine Rule (CCR)

  1. Rick says:

    Great article but how many times does the CCR have to be studied in the field. There was a study I believe conducted beeetween 2005-2009 which included multiple regions in Ontario plus Nova Scotia and maybe a couple of other provinces. And it concluded and recommended the use of the CCR in the field environment infact there are provinces in Canada that use the CCR. I would like to know why our province is dragging its heels on the use of CCR. The Swedish Institue of Trauma and Rescitation call the CCR the Gold Standard for clearing C-Spine. Just a thought again great article

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