 Welcome back to EM Ottawa trauma video. In this segment, we will discuss the Canadian C-spine and C-T head rules. The next patient is a 64-year-old who has slipped and fallen down her front steps. She is complaining of neck pain and a headache. She's had a brief loss of consciousness. Examination reviews only headache and tenderness in her cervical spine. Thus, she needs a C-spine X-ray. We'll be using the Canadian C-spine rule to help us decide. This rule applies to patients that you're worried about a cervical spine injury. It can only be applied to the alert and stable trauma patient. This rule divides patients into high and low-risk categories. High-risk patients need to have at least an X-ray of their cervical spine. These include patients who are older than 65, those with parasthesias in the extremities, and those who are involved in the following injury mechanisms, or fall, more than 5 steps or 3 feet. Axial loading, such as diving, high-speed motor vehicle collision, over 100 km per hour, those involving rollover or ejection, a bicycle or motorized recreational vehicles that are involved, such as all-terrain vehicles. Patients with any high-risk factors need to have at least an X-ray of their cervical spine. The rule also identifies low-risk factors that allow the cervical spine to be cleared clinically without an X-ray. Let us go through them. They can be simple rear-ended MVC without rollover, high-speed, or hit by a truck or a bus. Patients who is in sitting position in the emergency department. Patients who is ambulatory at any time after the injury. Patients who have neck pain that occurs after the injury. And no midline tenderness. Note that the patient only needs any of these characteristics to count as low-risk. If the patient has any of these low-risk factors, you will ask them to rotate their neck actively. If they can move their neck more than 45 degrees on both sides, no X-rays is needed. Their C-spine is now cleared clinically. If they cannot move their neck 45 degrees on both sides, the patient will need an X-ray of their C-spine. If your patient does not have any of these low-risk factors, they also need an X-ray. Using this rule, does our patient need an X-ray of a C-spine? Well, we don't know too much about the mechanism of injury. If she has fallen more than 5 steps, then she will fit in the high-risk area because of dangerous mechanism. Let's say she doesn't. And she has been either sitting in the emergency department or she has been ambulatory at any time since the accident. We will ask her to move her neck. If she is able to do that, then no X-ray is needed according to this rule. Let's say you decide to do an X-ray of the C-spine. How do you interpret it? Usually, three images would be obtained. The AP view, the lateral view, and the open mouth odontoid view. Of the three, the lateral view gives us the most information. To review the lateral C-spine X-ray, you want to ensure this is an adequate film. You need to be able to see from C1 down to the top of T1. Let's see if we can do this here. Here is C1, C2, 3, 4, 5, 6, 7, T1. Yes, this would be an adequate C-spine film. Now, we isolate the bones and look at the alignment. To look at alignment, we draw a few lines across similar structures and to see if there is an unusual curvature or kink in the line. These lines include the anterior vertebral line, which is this line, the posterior vertebral line, which is this line, and the spinal laminar line. If these are smooth and does not seem to have any step in them, then the alignment is okay. We also look at the contours and cortices of the bones to see if there are any fractures. Each vertebral body should be shaped like a box. Next, we look at the soft tissues and tear to the bones, which is this density here. As a general rule, there should be less than 6 mm of soft tissue in front of C2. So, here's C2, and the soft tissue in front of it, which is this little sliver right here, should be less than 6 mm. And in front of C6, there should be less than 20 mm of soft tissue. If there is more soft tissue swelling, then you're worried about an acute injury bleeding into the space. On the odontoid view, we focus on the part that shows C1 and C2. Remember, the ring of C1 fits over the peg of C2. Here's a close-up of C1 over C2. We look to see if there is a fracture of the dens. It could be at the tip, at the base, or taking part of the C2 body with it. Then, we look to see if the lateral masses of C1 extend beyond the edge of C2. So this has to line up with here and not over. And this has to line up with here and not over this side. After that, we also look to see if the C1 lateral masses are symmetrical from the dens. That is, if this distance is the same as this distance. If they're not, then you worry there might be a burst fracture of C1 ring, making the ring further away from the dens, causing the lateral masses to move over here or here and causing it not to sit directly squarely over the dens. Using this C-spine rule, you can decide on whether the patient needs an x-ray of their C-spine. How about a CT scan of the head for this patient? We will use another clinical decision rule, the Canadian CT head rule. This rule applies to patients who have sustained a minor head injury with either one of witness loss of consciousness, amnesia, or confusion. Their GCS have to be between 13 and 15. There are few exceptions to this rule. This rule does not apply to children under the age of 16. It also does not apply to those who have higher risks of bleeding, such as those with congenital bleeding disorders, or if they're on anticoagulants. Under this rule, if the patients have certain clinical features, they should have a CT scan of the head. These features fall into three different categories. The patient, the mechanism of the injury, and the physical examination. First, the patient. High risk factors include H over 65, vomiting more than two episodes, amnesia before impact more than 30 minutes. That is, let's say the injury happens at 3.30. The patient should remember what she did before 3 o'clock. If she didn't, then that's a high risk feature. Second, mechanism. High risk factors in the mechanism include pedestrian struck by vehicle, an occupant who was ejected from a vehicle, a fall from more than five steps or three feet. Those are all high risk mechanism. What about examination? There are a few things we want to look for. One is the GCS. If the GCS in presentation is less than 13, that's a high risk, and so is GCS less than 15 at two hours after the injury. Or on examination, if you feel a step on the skull, that makes you think that there might be a skull fracture. Or on the examination, you feel a large, soft, buggy hematoma that makes you think there might be a skull fracture underneath that. Or if there are signs that suggest basal skull fracture, such as battle sign for bruising behind the ear, blood in the ear or hemo-tympanum, or raccoon eyes. They can also include CSF otteria, so CSF coming from the ear, or CSF rhino rear, CSF coming from the nose. Those would all be signs of basal skull fracture. What about a patient? Well, if she has fallen more than five steps, vomit it more than twice, or if she has any amnesia more than 30 minutes, she has to get a CT scan of the head. If she has none of these, and examination are normal for potential skull fracture, and the GCS returned to 15 two hours after the injury, then she does not need the CT scan of the head. Obviously, you want to keep in mind that she is not on any medication that can increase her bleeding risk. That concludes our trauma video series. We hope you find them useful. Thank you for watching.