Briefs: Cervical spine X-Ray rules

This week on Briefs I wanted to present – with limited comment – a synopsis of the NEXUS and Canadian C-Spine rules. In general, the most common reason we end up getting cervical spine films in the Peds ED is for midline C-Spine pain. I trust you’d all agree that it is important to understand why we do this, and can enumerate other reasons to order films for suspected C spine injury. The title of each links to the seminal articles.

NEXUS (National Emergency X-Radiography Utilization Study)
Multicenter, prospective, observational study of patients with blunt trauma for whom cervical spine X-rays were obtained.

Get C-spine films if:

  • Abnormal neurologic examination
  • Distracting or painful injury (like a femur fracture)
  • Depressed or altered mental status
  • Intoxication
  • Midline cervical tenderness

Canadian C-spine rule
A prospective cohort study in Canada evaluating patients with head or neck trauma.

Radiography is definitely recommended in high risk factors

  • Dangerous mechanism
  • Paresthesias

If none of the following low risk factors are present and the patient can actively rotate 45 degrees to left and right, then C-spine films may not be needed.

  • Simple rear-end MVC
  • Sitting position in the ED
  • Ambulatory at any time since injury
  • Delayed onset neck pain
  • Absence of midline C-spine tenderness

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The year in review

Happy Holidays everyone! I’d like to thank all of the readers who engaged me online and in person about the content of the PEMBlog this year. Throughout the course of the year I’ve been able to delve into a number of topics and learn quite a bit in the process. Without further ado I’d like to highlight a few of my favorite posts from the past year.

The 8-Part Bronchiolitis Series

I was reminded again over the past 48 hours what a dastardly disease bronchiolitis can be. Back at the beginning of the year I dove into bronchiolitis like never before covering the disease form a number of angles.


Ted Brenkert and I are very proud of our efforts to launch PEMCurrents, a Pediatric Emergency Medicine focused podcast. Our main goal has always been to present high yield topics in a bite sized format. Why listen to terrible talk radio when you can learn something during your commute to work? The ketamine episode is one of my favorite and clearly distills what we are trying to do.

Altered Mental Status & Shared Presentations

I really like the ability to share my presentations online using services like SlideShare and Scribd. I did this a number of times over the past year, most notably with a presentation on altered mental status, one of my favorite conditions to evaluate and manage in the ED.

Keeping things Brief

I have a very short attention span. Anyway, what was I talking about – oh yeah, my attention span. I think that the internet is the perfect place for bit sized education. In my humble opinion I feel that this is accomplished quite readily via the Briefs feature on the site. Most weeks I try to share a topic of interest in a quick hitting format. The one that seemed to net the most discussion at work this year was the one on Summer Penile Syndrome.

Totally teeming with tech topics and tools

Alliteration… sigh. For those of you that know me I’m sure you’d say that I’m a bit of a tech geek. I enjoy sharing some of my favorite tech tools and apps. One of my most favorite apps that I started using this year was the bookmark service Pocket.

That’s all for now – I plan on roaring into the new year tackling a diverse array of Pediatric Emergency Medicine focused topics in a multitude of formats across the web. Check me out on Twitter @PEMTweets and on facebook. I’ll be unveiling some new features and adding more multimedia content. Thank you again for a wonderful year and Happy Holidays!


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What I’m reading: A must read review of UTI criteria

In general it is a good idea to be familiar with the clinical practice guidelines of the American Academy of Pediatrics. We see enough UTIs in the ED that it is always helpful to review.

Check it out here

The big take home points are:

  • Diagnosis is MOST supported by pyuria and >50,000 colonies/mL on culture
  • Follow up should occur at 7-14 days post treatment to document resolution
  • In infants and toddler with first UTI they should undergo an outpatient ultrasound of the kidneys and bladder to identify congenital anomalies
  • Data does not support starting urinary antibiotic prophylaxis in children with or without grade I to IV vesicoureteral reflux. Thus a Voiding Cystourethrogram – VCUG is not recommended after the first UTI as it had been previously. This latter issue has been somewhat controversial with some Urologists.
  • If there are recurrent febrile UTIs then patients should have a VCUG

Here is a figure comparing probability of UTI in boys and girls – note the differences.

Probability girls and boys UTICheck out the sensitivity and specificity of various portions of the chemical urinalysis test.

UA sensitivity and specificityAnd finally, here are a number of different antibiotic choices – always consider local practice and resistance patterns when you make your choice.

UTI Antibiotic choices

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PEMCurrents strikes again – this time focusing on retropharyngeal abscesses

Ted Brenkert sticks his neck out to educate you on retropharyngeal abscesses. RPAs can be an especially worrisome diagnosis in young children who will present with fever, sore throat and limitation of neck movement.

Check it out here


and streaming live via SoundCloud

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