Post on 12-Sep-2021
To Backboardor Not To Backboard?
Spinal Clearance Protocols
Will Smith, MD, EMT-PMedical Director
Grand Teton National Park andJackson Hole Fire/EMS, Jackson, WY
www.wildmedconsulting.com
ObjectivesDiscuss current standard of care and
protocols regarding spine injuries.Review research on spine injuries and
evaluation/treatment standards.How to implement spine assessment
protocols into your system.
Spinal Immobilization1960-70’s
EMS standards developedConsensus and Common Sense
Thought to be best practiceNow changing?
Who needs to be immobilized?
Even if they walked away from this?
Spinal ImmobilizationDo we immobilize for:
Mechanism of Injury?
Symptoms and/or Physical finding?
Spinal ImmobilizationLittle research
Never been shown to improve outcomesHauswald, Acad Emerg Med 1998Malaysia vs. New Mexico
Spinal ImmobilizationBUT - Standard of Care (in U.S.)
One of the most common EMS proceduresMillions of patients immobilized each yearNot necessarily in other parts of the world
Most Current EMS ProtocolsApply spinal immobilization to all
patients with potential for spine injurybased on mechanism of injury
If in doubt - IMMOBILIZE!
The ResearchNo RCT to asses spinal immobilization
on trauma patient mortality, neurologicinjury, spinal stability, or adverse effectssustainedKwan, Cochrane Database 2001/2007 #2803
The ResearchNEXUS
Hoffman, et. al. - NEJM, July 2000
Canadian C-Spine RuleStiell, et. al. - JAMA, Oct 2001
NEXUSMajor Research - moves to a standard of
clinical spine clearance in emergencydepartments
Decreased imaging in 12.6 % (4,309 pts)N=34,069 patients
NEXUS All 5 criteria met = No Xray
1. No midline cervical tenderness2. No focal neurological defect3. Normal alertness4. No intoxication5. No painful distracting injury
Canadian C-Spine RuleMajor Research -Slightly different protocol - more if/then
Age listed as a factorMechanism still plays a roleRange of motion of neck final test
www.caep.ca
Malaysian /New Mexico Study5 yr retrospective chart review of 2
university hospitalsLess neurologic disability in
unimmobilized Malaysian patientsHauswald, Acad Emerg Med 1998
Disproves many theories that previouslyjustified widespread spine immobilization
Taking this to the field…Wilderness EMS
Rural EMS
Urban EMS
Wilderness EMSExtended Transport
2 hours to daysRisks of Spinal Immobilization
Decubitus ulcers, pt. discomfortAirway concerns - vomit, blood, etc.Extrication problems, rescuer risks
Risk vs. Benefit of Spinal Immobilization
Wilderness EMS
Wilderness EMSFocused Spine AssessmentAccepted protocol for Wilderness First
Responders (WFR)WMA, NOLS/WMI, SOLO
Risk vs. benefit of spinal immobilization
Rural EMSProlonged Transport
15 minutes to 1-2 hours
Pt. uncomfortable, no provider riskAirway concerns - vomit, blood, etc.Early stage 1 Decubitis Ulcers (redness)
Urban EMSRapid Transport
Less than 15 minutesPresent to emergency departments
Spine clearing protocolsNEXUS, Canadian C-Spine Rule
Xrays or CTs
Little risk to patients or EMS providersAirway concerns -vomit, blood, etc.
Flight EMSPatient’s cleared in referral ED’s by CT
and board certified EM physicians placedback on boards for transfer to traumacenters.
Why change what we’re doing?Patient ComfortAirway CompromiseBreathing CompromiseSkin CompromisePatient/Provider safety in certain settings
Some places have…MaineMichiganCaliforniaNational Park Service
Malaysia (by default)
Focused Spinal AssessmentProtocol Implementation
Review ResearchReferences are a startDo your own as well!
Medical Director / Medical ControlSupportCritical for success
Focused Spinal AssessmentProtocol Implementation
Review Established ProtocolsState of MaineNational Park Service
State of Maine
www.maine.gov/dps/ems
National Park Service
NPS EMS Field Manual, Version 02/05, Procedure 1150
Wilderness Medical Associates
www.wma.org
Focused Spinal AssessmentProtocol Implementation
Develop Protocol that works for yoursystemAge >65 get collar?Peds excluded?
Focused Spinal AssessmentProtocol Implementation
Good QA/QI programEducation of EMS ProvidersOngoing Review of Decisions and
Outcomes
SummaryNot everyone with blunt trauma needs
spinal immobilization in the ED or in thefield
Selective immobilization can and shouldbe done by prehospital providers
Questions???
Copy of lecture noteswww.wildmedconsulting.com