title: The out-of-hospital validation of the Canadian C-Spine Rule by paramedics.
abstract: OBJECTIVE
  We designed the Canadian C-Spine Rule for the clinical clearance of the cervical spine, without need for diagnostic imaging, in alert and stable trauma patients. Emergency physicians previously validated the Canadian C-Spine Rule in 8,283 patients. This study prospectively evaluates the performance characteristics, reliability, and clinical sensibility of the Canadian C-Spine Rule when used by paramedics in the out-of-hospital setting.
  
  
  METHODS
  We conducted this prospective cohort study in 7 Canadian regions and involved alert (Glasgow Coma Scale score 15) and stable adult trauma patients at risk for neck injury. Advanced and basic care paramedics interpreted the Canadian C-Spine Rule status for all patients, who then underwent immobilization and assessment in the emergency department to determine the outcome, clinically important cervical spine injury.
  
  
  RESULTS
  The 1,949 patients enrolled had these characteristics: median age 39.0 years (interquartile range 26 to 52 years), female patients 50.8%, motor vehicle crash 62.5%, fall 19.9%, admitted to the hospital 10.8%, clinically important cervical spine injury 0.6%, unimportant injury 0.3%, and internal fixation 0.3%. The paramedics classified patients for 12 important injuries with sensitivity 100% (95% confidence interval [CI] 74% to 100%) and specificity 37.7% (95% CI 36% to 40%). The kappa value for paramedic interpretation of the Canadian C-Spine Rule (n=155) was 0.93 (95% CI 0.87 to 0.99). Paramedics conservatively misinterpreted the rule in 320 (16.4%) patients and were comfortable applying the rule in 1,594 (81.7%). Seven hundred thirty-one (37.7%) out-of-hospital immobilizations could have been avoided with the Canadian C-Spine Rule.
  
  
  CONCLUSIONS
  This study found that paramedics can apply the Canadian C-Spine Rule reliably, without missing any important cervical spine injuries. The adoption of the Canadian C-Spine Rule by paramedics could significantly reduce the number of out-of-hospital cervical spine immobilizations.
authors.affiliation: Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada.
authors.forename: Christian
authors.initials: C
authors.lastname: Vaillancourt
authors.forename: Ian G
authors.initials: IG
authors.lastname: Stiell
authors.forename: Tammy
authors.initials: T
authors.lastname: Beaudoin
authors.forename: Justin
authors.initials: J
authors.lastname: Maloney
authors.forename: Andrew R
authors.initials: AR
authors.lastname: Anton
authors.forename: Paul
authors.initials: P
authors.lastname: Bradford
authors.forename: Ed
authors.initials: E
authors.lastname: Cain
authors.forename: Andrew
authors.initials: A
authors.lastname: Travers
authors.forename: Matt
authors.initials: M
authors.lastname: Stempien
authors.forename: Martin
authors.initials: M
authors.lastname: Lees
authors.forename: Doug
authors.initials: D
authors.lastname: Munkley
authors.forename: Erica
authors.initials: E
authors.lastname: Battram
authors.forename: Jane
authors.initials: J
authors.lastname: Banek
authors.forename: George A
authors.initials: GA
authors.lastname: Wells
mesh_terms: D000328:Adult; D002170:Canada; D002574:Cervical Vertebrae / Q000293:injuries*; D002983:Clinical Competence; D015331:Cohort Studies; D016001:Confidence Intervals; D003661:Decision Support Techniques; D004632:Emergency Medical Services / Q000379:methods / Q000592:standards*; D004634:Emergency Medical Technicians / Q000592:standards*; D005260:Female; D006801:Humans; D007103:Immobilization / Q000379:methods; D008297:Male; D008875:Middle Aged; D019838:Neck Injuries / Q000175:diagnosis / Q000628:therapy; D017063:Outcome Assessment, Health Care; D017410:Practice Guidelines as Topic; D011446:Prospective Studies; D015203:Reproducibility of Results; D018570:Risk Assessment; D012680:Sensitivity and Specificity; D013124:Spinal Injuries / Q000175:diagnosis* / Q000628:therapy*; D019564:Unnecessary Procedures / Q000706:statistics & numerical data; D014949:Wounds, Nonpenetrating / Q000175:diagnosis / Q000628:therapy