EMS Spinal Immobilization: Time for a Change?
-
Upload
daniel-kwan -
Category
Health & Medicine
-
view
405 -
download
1
description
Transcript of EMS Spinal Immobilization: Time for a Change?
EMS: Spinal ImmobilizationDaniel Kwan, MD
Objectives
Present a spinal immobilization patient case.
Review the current Fresno County spinal immobilization policy.
Review reasons for spinal immobilization.
Discuss the problems with spinal immobilization
Go over the new NAEMSP and ACSCT position statement.
Go over San Joaquin’s spinal immobilization policy.
Present new revision to CCEMS Policy.
Review the original case in light of new evidence.
EMS Case
53 yo F found laying next to her Ford Ranger truck. Pulled out in front of a Semi-truck traveling Southbound traveling at approx 55mph. Pt was self extricated, & assisted to the roadway.
Major passenger front-end damage to her truck noted w/ airbag deployment. Pt amnesic to the event. Pt noted lower abd pain, w/ abrasions/bruising to area of hip bones & across chest w/ mid-line lumbar pain, & poss LOC.
Pt GCS 15. Wanted to remove c collar because she needed to vomit.
Should we allow her to remove the collar?
Fresno County Policy Implement spinal immobilization
◦ Posterior midline spinal pain or tenderness with h/o or suspicion of trauma.
◦ H/o blunt trauma with a trauma score of <= 14
◦ Injuries distracting patient from distinguishing spinal pain (e.g., pelvic fracture, multi-system trauma, crush injury to hands or feet, long bone fracture proximal to the knee/elbow, or to the humerus/femur.
◦ Severe head or facial trauma.
◦ Numbness or weakness in any extremity after trauma.
◦ LOC 2/2 trauma
◦ AMS (including drugs, alcohol, and trauma) and : No history available; or
Found in setting of possible trauma (e.g. lying at the bottom of stairs or in street); or
Near drowning with a history of probability of driving injury.
Patients with need spinal immobilization are determined by above criteria and not mechanism of injury alone.
Reasons for Spinal
Immobilization Injured patients may have unstable
injury of the spine. Need to splint “joint
above and below”.
Prevent further injury to the spinal
cord as this can have high morbidity.
Determining pre-hospital spinal injury
can be difficult, so immobilize “just in
case”.
C Collars
Philadelphia
Soft
Miami J
Aspen
Backboards
Immobilize Everyone!
ATLS- Standard of care. Part of
ABCDE
ACS (Published new guideline in
2013)
Prehospital Trauma Life Support (Until
2011)
National Association of Emergency
Medical Technicians
Immobilize Everyone!
Missed C spine Injury in Trauma patients*
◦ 740 out of 32,117 trauma pts with CSI.
◦ Delayed or missed in 34 pts (4.6%)
◦ 10 of those 34 developed permanent sequelae.
◦ However, 31/34 missed 2/2 inadequate 3 view C spine XR
ER evaluation not adequate for spinal injury**
◦ Retrospective study from 1979
◦ Symptoms and physical exam findings not sufficient
◦ Immobilization of essentially all patients with potential
for spinal injury
*Davis JW, Phreaner DL, Hoyt DB, Mackersie RC. The etiology of missed cervical spine
injuries. J Trauma. 1993;34(3):342-6.
** Bohlman HH. Acute fractures and dislocations of the cervical spine. An analysis of three
hundred hospitalized patients and review of the literature. J Bone Joint Surg Am.
1979;61(8):1119-42.
Good or bad?
Patients still should get spinal
immobilization because the benefits
outweigh the risk
… right?
There are three types of patients
◦ Stable spinal fracture
◦ Unstable spinal fracture with neurological
deficit
◦ Unstable spinal fracture without neurological
deficit
Do we help those in the 3rd category?
Injured Patients May Have
Unstable Injury of Spine • 1-5 million patients receive spinal immobilization per year in
the US.
• Rate of c spine fx is 2-5%– Unstable C spine fx is 1-2%.
– Among these, ½ showed neuro deficits upon arrival. (0.5-1%)
• Blunt trauma– C spine fx rate is 1.2-3.3%
– C spine injury is 0.4-0.7%
• Penetrating Trauma*
– 1.43% had spinal fractures
– 0.38% had unstable spine fractures • 74% had completed spinal injury prior to immobilization
• NNT: 1032; NNH 66
*Haut ER, Kalish BT, Efron DT, et al. Spine immobilization in penetrating trauma: more harm
than good?. J Trauma. 2010;68(1):115-20.
Further Movement Can Cause
Additional Injury Is the force enough?
◦ C spine fractures when >2,000-6,000
Newtons.
◦ L spine requires >4200 Newtons (even in
elderly).
◦ Hanging 4 kg head off the end of a stretcher-
40 Newtons
◦ Force after injury is diffused.
Malaysia vs New Mexico Study
Awake pts may protect their own spine if
they are awake.
Application of Spinal
Immobilization Prevents Motion
Correctly fitted collars allow over 30 degrees of flexion/extension. 16 degrees of lateral bending. Rotation about 27 degrees.
Could increase motion C1-C2 level. Paradoxical extension.
Approx 7.7 mm motion in axial plane and 2.9 mm in the cranial caudal direction in cadaver models.
During extrication, no movement reduction is added to C-collar by using a backboard.
Immobilization is a relatively
harmless measure, so apply as
“a precaution”.
Complications
◦ Back pain
◦ Respiratory Compromise
◦ ICP increase
◦ Increased aspiration
◦ Airway management difficulty
◦ Distracting an unstable fracture
◦ Delay in arriving to trauma center
◦ Cost
Back Pain
Small Prospective Study*
◦ 21 healthy volunteers
◦ Immobilized for 30 minute period.
◦ Results: occipital headache, sacral/lumbar
back pain, mandibular pain most
common.
◦ 55% subjects graded their symptoms as
moderate to severe.
◦ 29% developed symptoms 48 hours later
*Chan D, Goldberg R, Tascone A, Harmon S, Chan L. The effect of spinal
immobilization on healthy volunteers. Ann Emerg Med. 1994;23(1):48-51.
Respiratory Compromise
Backboard alone*
◦ 15 nonsmoking male volunteers
◦ Zee Extrication Device and Long Spinal board
◦ Sig differences in FVC and FEV1.
Backboard and cervical collar**
◦ 39 randomized crossover laboratory study
◦ Immobilized with philadelphia collar on hard wooden
backboard or Scandinavian vacuum mattress.
◦ 15% decrease in FEV1 on average. (worse at extremes of
age).
◦ Vacuum mattress more comfortable. *Bauer D, Kowalski R. Effect of spinal immobilization devices on pulmonary
function in the healthy, nonsmoking man. Ann Emerg Med. 1988;17(9):915-8.
**Totten VY, Sugarman DB. Respiratory effects of spinal immobilization. Prehosp
Emerg Care. 1999;3(4):347-52.
Increased ICP
Head injury occurs in 34% of trauma
patients
27% of trauma deaths
◦ More common than c spine injury
◦ AMS difficult to clear c spine.
Rise in ICP is 4.5 mm Hg on average. *
Mechanism
◦ Painful stimulus
◦ Disrupted Venous Flow***Hunt K, Hallworth S, Smith M. The effects of rigid collar placement on intracranial and cerebral
perfusion pressures. Anaesthesia. 2001;56(6):511-3.
**Stone MB, Tubridy CM, Curran R. The effect of rigid cervical collars on internal jugular vein
dimensions. Acad Emerg Med. 2010;17(1):100-2.
Increased Aspiration
Decreased ability to open mouth
Difficulty swallowing
Head Injury patients can vomit.
Houghton DJ, Curley JWA. Dysphagia caused by a hard cervical
collar. British Journal of Neurosurgery 1996;10(5):501–2.
Difficulty Managing Airway
Collar vs Manual Inline Stabilization (MILS)
◦ Manual inline stabilization (MILS) better than collar and board.
◦ 56% had 1 grades better and 10% had 2 grades better with MILS
MILS only **
◦ 200 Elective surgery patients
◦ Single blinded randomization to MILS vs not
◦ 50% had failure rate in 30 seconds with MILS vs 5.7% without.
*Heath KJ. The effect of laryngoscopy of different cervical spine immobilisation techniques. Anaesthesia.
1994;49(10):843-5.
** Thiboutot F, et al. Effect of manual in-line stabilization of the cervical spine in adults on the rate of difficult
orotracheal intubation by direct laryngoscopy: a randomized controlled trial. Can J Anaesth.
2009;56(6):412-8.
Distracting Unstable Fracture
Ankylosing Spondylitis
◦ Extension of spine during
immobilization neuro deficits.
Malaysia (No collar) vs New Mexico
(routine collar)
◦ Increased frequency of neurological
deterioration
◦ More overall neuro disability.
Delayed Resuscitation
Prehospital care◦ Trauma pts may have better outcomes with
less.
◦ Severe trauma pts had better outcomes when transported with private vehicle.
◦ Canadian study- ALS programs worsened outcomes in those with severe TBI.
Penetrating trauma patients◦ Retrospective analysis of 45,284 patients
◦ OR 2.06 (1.35-3.13) of death in those immobilized
◦ NNT 1032, NNH 66
Cost
Backboards/C-collars
C-collars beget imaging to “clear the c
collar”.
Increased morbidity.
Prehospital Trauma Life
Support Recommendations (2011)◦ There are no data to support routine spinal
immobilization in patients with penetrating trauma to the neck or torso.
◦ There are no data to support the routine spinal immobilization in patients with isolated penetrating trauma to the cranium.
◦ Spinal immobilization should never be done at the expense of physical examination or correction of life-threatening conditions in patients with penetrating trauma.
◦ Spinal immobilization may be performed when a focal neurological deficit is noted although there is little evidence of benefit even in these cases.
National Association of EMS
Physicians and ACS on Trauma Position Statement on Backboards 2013
Utilization of backboards should be
judicious.
◦ Appropriate patients for immobilization
Blunt trauma and AMS
Spinal Pain or Tenderness
Neurologic Complaint
Anatomic deformity of the spine
High energy mechanism of injury or any of the
following
Drug or ETOH intoxication
Inability to communicate
Distracting injury
National Association of EMS
Physicians and ACS on Trauma Backboard Immobilization not
necessary◦ Normal level of consciousness (GCS 15)
◦ No spine tenderness or anatomic abnormality
◦ No neurologic findings of complaints
◦ No distracting injury
◦ No intoxication
Penetrating trauma to the head, neck, and torso and no evidence of spinal injury should not be immobilized on a backboard
National Association of EMS
Physicians and ACS on Trauma Spinal precautions can be maintained
by application of a rigid cervical collar and securing the patient firmly to the EMS stretcher, and maybe most appropriate for:◦ Pts who are ambulatory at scene
◦ Pts who must be transported for protracted time, particularly prior to interfacility transfer
◦ Pts for whom backboard is not otherwise indicated
San Joaquin County Policy
Apply C spine immobilization in blunt force trauma pts◦ Posterior midline cervical tenderness or pain
◦ Distal numbness, tingling, weakness, paresthesia
◦ Paralysis
◦ Neck guarding or restricted ROM
◦ GCS motor score 5
◦ Unconscious pt except GLF
Do not apply c spine immobilization◦ Penetrating Trauma
◦ Unconscious adult GLF
◦ Cardiac arrest
Backboards may be used for extrication or movement at scene, but not for transport to the hospital.
CCEMS Policy RevisionsSpinal Immobilization
No Neck Pain
or Tenderness
Neck Pain or
Tenderness
Neuro Signs
or Symptom
Altered
Mental Status
AmbulatoryPosition of
Comfort
Gurney
Position of
Comfort
with/without
Support
FullPosition of
Comfort
Non-
ambulatory
Position of
Comfort
Gurney
supine
Position of
Comfort with
extrication
support
Full Full
Severe
Multisystem
Trauma
Full Full Full Full
Back to the case…
Pt is GCS 15 and ambulatory (self-
extricated)
Back pain, abd pain but no neck pain.
No neurological symptoms
Per our new policy, this could be a
person that could be transported
without cervical collar or backboard.
Summary
True unstable spinal injuries are rare.
Ambulatory patients may protect their own spine.
C collars do not fully immobilize neck movement.
Spinal immobilization is not without complications.
New guidelines do not recommend routine backboard usage. ◦ Use NEXUS and Canadian C spine as guides
Other systems are changing their policies to have more judicious usage of spinal immobilization.
CCEMS is revising the current policy as well
References1. Davis JW, Phreaner DL, Hoyt DB, Mackersie RC. The etiology of missed
cervical spine injuries. J Trauma. 1993;34(3):342-6.
2. Bohlman HH. Acute fractures and dislocations of the cervical spine. An analysis of three hundred hospitalized patients and review of the literature. J Bone Joint Surg Am. 1979;61(8):1119-42.
3. Haut ER, Kalish BT, Efron DT, et al. Spine immobilization in penetrating trauma: more harm than good?. J Trauma. 2010;68(1):115-20.
4. Hauswald M, Ong G, Tandberg D, Omar Z. Out-of-hospital spinal immobilization: its effect on neurologic injury. Acad Emerg Med. 1998;5(3):214-9.
5. Bandiera G, Stiell IG, Wells GA, Clement C, De Maio V, Vandemheen KL, Greenberg GH, Lesiuk H, Brison R, Cass D, Dreyer J, Eisenhauer MA, Macphail I, McKnight RD, Morrison L, Reardon M, Schull M, Worthington J, on behalf of the Canadian C-Spine and CT Head Study Group The Canadian C-spine rule performs better than unstructured physician judgment. Ann EmergMed. 2003;42:395–40.
6. James CY, Riemann BL, Munkasy BA, Joyner AB: Comparison of Cervical Spine Motion During Application Among 4 Rigid Immobilization Collars. J AthlTrain 2004, 39(2):138-145.
7. Hughes SJ. How effective is the Newport/Aspen collar? A prospective radiographic evaluation in healthy adult volunteers. J Trauma. 1998;45(2):374-8.
8. Chin KR, Auerbach JD, Adams SB, Sodl JF, Riew KD. Mastication causing segmental spinal motion in common cervical orthoses. Spine. 2006;31(4):430-4.
References1. Engsberg JR, Standeven JW, Shurtleff TL, Eggars JL, Shafer JS, Naunheim
RS. Cervical spine motion during extrication. J Emerg Med. 2013;44(1):122-7.
2. Chan D, Goldberg R, Tascone A, Harmon S, Chan L. The effect of spinal immobilization on healthy volunteers. Ann Emerg Med. 1994;23(1):48-51.
3. Bauer D, Kowalski R. Effect of spinal immobilization devices on pulmonary function in the healthy, nonsmoking man. Ann Emerg Med. 1988;17(9):915-8.
4. Totten VY, Sugarman DB. Respiratory effects of spinal immobilization. PrehospEmerg Care. 1999;3(4):347-52.
5. Hunt K, Hallworth S, Smith M. The effects of rigid collar placement on intracranial and cerebral perfusion pressures. Anaesthesia. 2001;56(6):511-3.
6. Stone MB, Tubridy CM, Curran R. The effect of rigid cervical collars on internal jugular vein dimensions. Acad Emerg Med. 2010;17(1):100-2.
7. Thumbikat P, Hariharan RP, Ravichandran G, Mcclelland MR, Mathew KM. Spinal cord injury in patients with ankylosing spondylitis: a 10-year review. Spine. 2007;32(26):2989-95.
8. Stiell IG, Nesbitt LP, Pickett W, et al. The OPALS Major Trauma Study: impact of advanced life-support on survival and morbidity. CMAJ. 2008;178(9):1141-52.
9. EMS spinal precautions and the use of the long backboard. Prehosp EmergCare. 2013;17(3):392-3.
Thanks!