Advanced Trauma Life Support ATLS Student Course Manual 2018

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CHAPTER 7 n Spine and Spinal Cord Trauma
National Emergency X-Radiography Utilization Study
(NEXUS) Criteria
Meets ALL low-risk criteria?
1. No posterior midline cervical-spine tenderness
and…
2.
No evidence of intoxication
and…
3.
A normal level of alertness
and…
4.
No focal neurologic deficit
and…
5.
No painful distracting injuries
YES
No Radiography
NO
Radiography
NEXUS Mnemonic
N– Neuro deficit
E – EtOH (alcohol)/intoxication
X– eXtreme distracting injury(ies)
U– Unable to provide history (altered level of consciousness)
S – Spinal tenderness (midline)
n FIGURE 7-9 National Emergency X-Radiography Utilization Study
(NEXUS) Criteria and Mnemonic. A clinical decision tool for cervical
spine evaluation. Adapted from Hoffman JR, Mower WR, Wolfson
AB, et al. Validity of a set of clinical criteria to rule out injury to the
cervical spine in patients with blunt trauma. National Emergency
X-Radiography Utilization Study Group. N Engl J Med 2000;
343:94–99.
Explanations:
These are for purposes of clarity only. There are not precise
definitions for the individual NEXUS Criteria, which are
subject to interpretation by individual physicians.
1. Midline posterior bony cervical spine tenderness is
present if the patient complains of pain on palpation
of the posterior midline neck from the nuchal ridge
to the prominence of the first thoracic vertebra, or
if the patient evinces pain with direct palpation of any
cervical spinous process.
2. Patients should be considered intoxicated if they have
either of the following:
• A recent history by the patient or an observer of
intoxication or intoxicating ingestion
• Evidence of intoxication on physical examination, such
as odor of alcohol, slurred speech, ataxia, dysmetria
or other cerebellar findings, or any behavior consistent
with intoxication. Patients may also be considered to
be intoxicated if tests of bodily secretions are positive
for drugs (including but not limited to alcohol) that
3. An altered level of alertness can include
any of the following:
• Glasgow Coma Scale score of 14 or less
• Disorientation to person, place, time, or events
• Inability to remember 3 objects at 5 minutes
• Delayed or inappropriate response to external stimuli
• Other
4. Any focal neurologic complaint (by history) or finding
(on motor or sensory examination).
5. No precise definition for distracting painful injury is
possible. This includes any condition thought by the
patient from a second (neck) injury. Examples may
include, but are not limited to:
• Any long bone fracture
• A visceral injury requiring surgical consultation
• A large laceration, degloving injury, or crush injury
• Large burns
• Any other injury producing acute functional impairment
Physicians may also classify any injury as distracting if it
is thought to have the potential to impair the patient’s
ability to appreciate other injuries.
There are two options for patients who require radiographic
evaluation of the cervical spine. In locations
with available technology, the primary screening
modality is multidetector CT (MDCT) from the occiput
to T1 with sagittal and coronal reconstructions. Where
this technology is not available, plain radiographic
films from the occiput to T1, including lateral,
anteroposterior (AP), and open-mouth odontoid
views should be obtained.
With plain films, the base of the skull, all seven
cervical vertebrae, and the first thoracic vertebra must
be visualized on the lateral view. The patient’s shoulders
may need to be pulled down when obtaining this x-ray
to avoid missing an injury in the lower cervical spine.
If all seven cervical vertebrae are not visualized on the
lateral x-ray film, obtain a swimmer’s view of the lower
cervical and upper thoracic area.
The open-mouth odontoid view should include the
entire odontoid process and the right and left C1 and
C2 articulations.
The AP view of the c-spine assists in identifying a
unilateral facet dislocation in cases in which little or
no dislocation is visible on the lateral film.
When these films are of good quality and are properly
interpreted, unstable cervical spine injuries can be
detected with a sensitivity of greater than 97%. A
doctor qualified to interpret these films must review
the complete series of cervical spine radiographs
before the spine is considered normal. Do not remove
the cervical collar until a neurologic assessment and
evaluation of the c-spine, including palpation of the
spine with voluntary movement in all planes, have
been performed and found to be unconcerning or
without injury.
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