Paucis Verbis card: Cervical spine imaging rules

CervicalCollarThere is constant debate on whether to image the cervical spine of blunt trauma patients. Fortunately, there are two clinical decision tools available to help you with your evidence-based practice.

The NEXUS and Canadian C-spine Rules (CCR) are both validated studies which both quote a high sensitivity (over 99%) in detecting clinically significant cervical spine fractures. Both studies primarily used plain films in evaluating their patients.

Sensitivity (%)Specificity (%)



National Emergency X-radiography Utilization Study

A patient’s neck can be clinically cleared safely without radiographic imaging if all five low-risk conditions are met:

  1. No posterior midline neck pain or tenderness
  2. No focal neurological deficit
  3. Normal level of alertness
  4. No evidence of intoxication
  5. No clinically apparent, painful distracting injury*

* Defined as “a condition thought by the clinician to be producing pain sufficient to distract the patients from a second (neck) injury. Examples may include, but are not limited to the following:

  1. Long bone fracture,
  2. A visceral injury requiring surgical consultation,
  3. A large laceration, degloving injury, or crush injury,
  4. Large burns, or
  5. 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.”

Canadian C-spine Rules (CCR)

The basic approach in this flow-chart is to (1) make sure that the patient meets the same inclusion criteria as in the CCR study. Then (2) determine if there are high-risk findings. If so, go directly to imaging. (3) If there are no high-risk findings, check to see if the patient qualifies as a low-risk candidate where you might be able to clinically clear the c-spine without imaging. (4) If the patient is neither high or low risk, then the patient is moderate risk and requires imaging. Here’s a flow chart that I made to help you remember:

Go to ALiEM (PV) Cards for more resources.

Note: Many emergency physicians go straight to CT imaging for patients with neck tenderness and moderate/high risk findings. I personally rarely use the CCR algorithm because I can rarely remember all of the criteria. NEXUS is nice because of its simplicity. Where the CCR algorithm IS helpful is in clinical clearance of the low-risk patient with neck pain. I’ve cleared many patients who self-present with a whiplash mechanism (simple rear-end motor vehicle crash) and diffuse neck pain. By NEXUS criteria, you’d have to image them because they have neck tenderness. By CCR criteria, if they can actively rotate their neck 45 degrees left and right, they don’t have a clinically significant c-spine injury. No imaging needed.

By |2021-10-17T09:17:48-07:00Dec 10, 2010|ALiEM Cards, Orthopedic, Trauma|

Paucis Verbis card: Penetrating abdominal trauma

penetrating abdominal traumaWhen I did my residency training in Emergency Medicine and in the first few years as an attending, we regularly performed diagnostic peritoneal lavages in patients with stab wounds injuries to the abdomen. Patients also routinely went to the operating room for exploration.

Now with the evolution of CT imaging technology and more clinical studies, there is now a role for a less invasive management approach. These are the Eastern Association for the Surgery of Trauma (EAST) guidelines.

PV Card: Penetrating Abdominal Trauma

Adapted from [1]
Go to ALiEM (PV) Cards for more resources.


  1. Como JJ, Bokhari F, Chiu WC, et al. Practice Management Guidelines for Selective Nonoperative Management of Penetrating Abdominal Trauma. The Journal of Trauma: Injury, Infection, and Critical Care. 2010;68(3):721-733. doi: 10.1097/ta.0b013e3181cf7d07
By |2021-10-18T10:21:39-07:00Jul 9, 2010|ALiEM Cards, Trauma|

Paucis Verbis card: Burn Wounds

burn woundsBurn classification and management are key skills for ED providers to remember. Depending on the prevalence of burns in your ED, it may be hard for forget the details. So here is a PV reference card on the rule of 9’s, different classifications of burns, and indications for burn unit referral.

Update (April 22, 2016): This card was updated by Dr. Christian Rose (UCSF-SFGH) to reflect current evidence that topical antibiotics and honey are IN, while silver sulfadiazine is OUT for partial-thickness burns.

PV Card: Burn Wounds

Adapted from [1-3]
Go to ALiEM (PV) Cards for more resources.


  1. Gómez R, Cancio L. Management of burn wounds in the emergency department. Emerg Med Clin North Am. 2007;25(1):135-146. [PubMed]
  2. Malik K, Malik M, Aslam A. Honey compared with silver sulphadiazine in the treatment of superficial partial-thickness burns. Int Wound J. 2010;7(5):413-417. [PubMed]
  3. Jull A, Cullum N, Dumville J, Westby M, Deshpande S, Walker N. Honey as a topical treatment for wounds. Cochrane Database Syst Rev. 2015;(3):CD005083. [PubMed]
By |2021-10-18T10:23:37-07:00Jul 2, 2010|ALiEM Cards, Dermatology, Trauma|

Paucis Verbis card: Pediatric blunt head injury

Epidural hemorrhage blunt head traumaIn this installment of the Paucis Verbis (In a Few Words) e-card series, the topic is Pediatric Blunt Head Trauma.

This a particularly relevant topic given the recent press and discussions about CT irradiation and the cancer risk especially in pediatric patients. It’s also relevant since Dr. Nate Kuppermann (UC Davis) just gave Grand Rounds at our UCSF-SFGH EM residency program. He first-authored a landmark 2009 Lancet article on minor head injury in kids.

PV Card: Pediatric Blunt Head Trauma

Adapted from [1]
Go to ALiEM (PV) Cards for more resources.


Update June 27, 2017

We collaborated with PECARN and CanadiEM to create visual PECARN’s official decision tool.


  1. Kuppermann N, Holmes J, Dayan P, et al. Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet. 2009;374(9696):1160-1170. [PubMed]
By |2021-10-19T19:12:36-07:00Feb 5, 2010|ALiEM Cards, Pediatrics, Trauma|

Trick of the Trade: Modified hair apposition technique

modified hair apposition technique

I got a nice email from Dr. John Fowler from Turkey who recently published a modified version of the Hair Apposition Technique (HAT) trick in the American Journal of Emergency Medicine in 2009.

Read more about the traditional HAT trick.

The HAT trick allows for scalp laceration closure by using scalp hair and tissue adhesive glue. Contraindications to this technique for wound closure include hair strands less than 3 cm, because it is difficult to manually manipulate short hair.


By |2019-11-29T19:03:44-08:00Jan 20, 2010|Trauma, Tricks of the Trade|
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