Don’t request imaging of the cervical spine in trauma patients, unless indicated by a validated clinical decision rule.
Cervical spine imaging of every trauma patient is costly and results in significant radiation exposure to a large number of patients, very few of whom will have a spinal column injury. Clinical decision rules have been developed that identify patients who can safely be managed without imaging. These rules include the Canadian C-Spine rule or Nexus Low Risk Criteria. The Canadian C-Spine Rule provides higher specificity and lower imaging requirements, and should be used if possible.
This is a joint recommendation with The Royal Australian and New Zealand College of Radiologists (RANZCR).
- Stiell IG, Wells GA, Vandemheen KL, Clement CM, Lesiuk H, De Maio VJ, Laupacis A, Schull M, McKnight RD, Verbeek R, Brison R, Cass D, Dreyer J, Esenhauer MA, Greenberg GH, MacPhail I, Morrison L, Reardon M, and Worthington J. The Canadian C-spine rule for radiography in alert and stable trauma patients. JAMA. 2001;286(15):1841-1848.
- Stiell IG, Clement CM, McKnight RD, Brison R, Schull MJ, Rowe BH, et al. The Canadian C-spine rule versus the NEXUS low-risk criteria in patients with trauma. N Engl J Med. 2003;349(26):2510‐8.
- Anderson PA, Muchow RD, Munoz A, Tontz WL, and Resnick DK. Clearance of the asymptomatic cervical spine: a meta-analysis. J Orthop Trauma. 2010;24(2):100‐106.
A Choosing Wisely Working Group of 9 emergency physicians identified an initial list of 10 potential items. All ACEM members were able to provide feedback on these items and suggest other issues for consideration. This feedback informed Working Group refinement of the initial list into 8 recommendations. Evidence reviews were then completed for each recommendation. These evidence reviews, frequency of use in ED, risks/benefit to patient and cost were used as criteria for Working Group member voting in order to determine the final 6 recommendations. These recommendations have been endorsed by ACEM's Council of Advocacy, Practice and Partnerships.
Following identification of two common recommendations with the Royal Australian and New Zealand College of Radiologists, it was agreed by both Colleges to jointly present these items.
Avoid requesting computed tomography (CT) imaging of kidneys, ureters and bladder (KUB) in otherwise healthy emergency department patients, age <50 years, with a known history of kidney stones, presenting with symptoms and signs consistent with uncomplicated renal colic.
Avoid coagulation studies in emergency department patients unless there is a clearly defined specific clinical indication, such as for monitoring of anticoagulants, in patients with suspected severe liver disease, coagulopathy, or in the assessment of snakebite envenomation*.
- 3 Avoid blood cultures in patients who are not systemically septic, have a clear source of infection and in whom a direct specimen for culture (e.g. urine, wound swab, sputum, cerebrospinal fluid, or joint aspirate) is possible.
- 4 For emergency department patients approaching end-of-life, ensure clinicians, patients and families have a common understanding of the goals of care.
- 5 Don’t request imaging of the cervical spine in trauma patients, unless indicated by a validated clinical decision rule.
- 6 Don’t request computed tomography (CT) head scans in patients with a head injury, unless indicated by a validated clinical decision rule.