EMS Spinal Immobilization
Paul Spellman, MDEMS Physician
The Historyat some point someone thought it would be a good idea - Dr. Farrington - Trauma Surgeon in 1968Backboarding enters DOT EMT curriculum in 1984 but it was widely used prior to entering the curriculum if we immobilize a long bone fracture, then we should do the same with the spine
The Problemthis idea wasnt founded on any research!!!!!just because something seems like a good idea, doesnt mean that it actually is a good idea
Evidence Based Medicinetheres risks and benefits to any medical treatmentBenefits should be:effective spinal immobilizationimproved patient outcomesnew research suggests that for many/most patients the risks outweigh the benefits
Downside of Backboarding
The Reality - Blunt Trauma1998 Study by Hauswald compared University of New Mexico to University of Malaysia (5yr retrospective study comparing outcomes)neurological deterioration was less prevalent in patients in Malaysia that were not backboarded1999 Perry, et al found that spinal immobilization techniques were ineffective at limiting spinal motion during simulated vehicle motion (ie patient transport)
Interesting Statistics1-5 Million patients placed in spinal immobilization per year1-3% of severely traumatized patients with cervical fracture.4-.7% have unstable cervical fracture50-70% of patients with unstable cervical fracture have a completed spinal cord injury
The Reality - Penetrating TraumaJournal of Trauma 2006 article studied assault victims in Las Angeles57,532 assault victims0.41% had cervical fractureGSWs had 1.35%, Stabbing had 0.11%
Precautionary ImmobilizationIts estimated that at least five million patients are immobilized in the prehospital environment in the U.S. each year. Most have no complaints of neck or back pain or other evidence of spine injuryEMS personnel were not traditionally given protocols or authority to determine the need for spinal immobilizationthis was based on false belief that immobilization was always the safest option !!!!!!!!!
Paradigm ShiftSome prehospital care providers will admit that they often immobilize patients without evidence of spine injury because they want to avoid being questioned on arrival at the emergency departmentThis dynamic can (and must) change with education and outreach
Conclusionthe number of cases where backboarding served its intended purpose is dwarfed by the number of cases where it served no purpose other than to delay transport and increase costs of emergency care
New PhilosophySpinal immobilization can cause potential harm to the patient and may in some cases delay or impede life saving care It should not be preformed without the proper justification Consider risks of immobilization vs risks of not immobilizing You must also consider the time involved in immobilization and delay of patient transport.
New Definition of Spinal ImmobilizationSpinal immobilization will consist of an appropriately sized cervical collar and securing the patient adequately to the stretcher
Adjuncts for ImmobilizationThese are other tools to be used to assist in moving a patient who is unable or unwilling to move due to pain or injury
ConsiderationsIf secondary devices are used to assist with patient transport and immobilization the method selected should:Minimize gross movement of the spineMinimize patient discomfortAllow for adequate airway protection
Purpose of a BackboardExtrication DeviceFirm Surface for chest compressions
Patient Self-ExtricationMay be allowed if the patient is alert and cooperativePatient should be able to assist in limiting gross movement of the spineApply collar and ask patient to limit bending and rotation of the spineAssist patient out of vehicle/circumstance to a waiting stretcher placed as close as possible to the patient
Self Extrication ContinuedThis option should be reserved for situations where mechanism of injury is less likely to produce spinal injury Any patient stating they are in too much pain to self extricate should be extricated in traditional fashion by EMS providers
Patient MonitoringAny patient who undergoes spinal immobilization should have frequent reassessments of their airway and neurologic status
DocumentationCareful documentation should be done detailing the rationale for the selected method of spinal immobilization or the decision to not use spinal immobilization This documentation will include a detailed physical exam of the patients vertebral column, a detailed neurologic exam, an assessment of the patients mental status and competency, as well as the presence or absence of distracting injuries
Who Needs Spinal Immobilization?If the answer to either of these questions is yes, the patient should undergo spinal immobilization. If the answer to both of these questions is no, the patient may be transported in a position of comfort. 1 Is the patient or their exam unreliable? 2 Does the patient have an abnormal spine or neurologic exam?
Reliable Exam patient must be mentally competent with no signs of altered mental status or intoxicationmust not have a distracting injury causing pain that would mask spinal tendernessthe patient must have no language barriers preventing clear communication with the EMS crewThe patient must not have dementiaThe patient must not be someone less than 5 years old or greater than 65 years old who has a significant mechanism of injury. The threshold for significant mechanism of injury is much lower in the elderly.
Abnormal Spine or Neuro Exampain to palpation of the vertebral column. any pain in the vertebral column with range of motion movement. Do not assess range of motion if the patient has tenderness of the vertebral column or already meets the criteria for spinal immobilization. deformities of the spinal column. motor or sensory deficits. tingling in the extremities, even in the presence of intact sensation.
Drowning Victimsshould not undergo spinal immobilization unless there is a clear history of trauma discovered in the history or exam Spinal immobilization (especially if done in the water) may delay life saving resuscitative efforts such as quality chest compressions
Penetrating Traumaimmobilization for victims of penetrating trauma may delay life saving surgical intervention
When to Immobilize Penetrating TraumaObvious neurologic deficit in the extremitiesSignificant secondary blunt mechanism of injury (ex: fall down the stairs after sustaining a gunshot wound)PriapismNeurogenic shockAnatomic deformity to the spine secondary to the injury
Ambulatory PatientsPatients who are ambulatory at the scene and who meet the criteria for spinal immobilization may be assisted to a nearby stretcher and immobilized Ambulatory patients should not be placed on a backboardcervical collar should be applied and they can be secured adequately to the stretcher
Infant Car SeatsInfants restrained in a rear facing car seat may be extricated and immobilized in the car seat They may remain there if they are secure and their condition allows
Combative PatientsCombative patients should be immobilized in a way that does not provoke increased spinal movement or combativeness These cases should be carefully documented
New KY State Protocol
Selective Spine Immobilization
In ConclusionThis change has been a long time comingState Protocol can be used by agencies currently using the state protocols, others will have to submit protocol for approvalLocal Medical Directors all seem to be supportiveWe will establish a new local standard of care??????s