EMS Spinal EMS Spinal ImmobilizationImmobilization

Paul Spellman, MDPaul Spellman, MD

EMS PhysicianEMS Physician

The HistoryThe Historyat some point someone thought it would be a at some point someone thought it would be a good idea - Dr. Farrington - Trauma Surgeon in good idea - Dr. Farrington - Trauma Surgeon in 19681968

Backboarding enters DOT EMT curriculum in Backboarding enters DOT EMT curriculum in 1984 but it was widely used prior to entering 1984 but it was widely used prior to entering the curriculum the curriculum

if we immobilize a long bone fracture, then we if we immobilize a long bone fracture, then we should do the same with the spineshould do the same with the spine

The ProblemThe Problem

this idea wasn’t founded on any research!!!!!this idea wasn’t founded on any research!!!!!

just because something seems like a good just because something seems like a good idea, doesn’t mean that it actually is a good idea, doesn’t mean that it actually is a good ideaidea

Evidence Based Evidence Based MedicineMedicine

there’s risks and benefits to any medical there’s risks and benefits to any medical treatmenttreatment

Benefits should be:Benefits should be:

effective spinal immobilizationeffective spinal immobilization

improved patient outcomesimproved patient outcomes

new research suggests that for many/most new research suggests that for many/most patients the risks outweigh the benefitspatients the risks outweigh the benefits

Downside of Downside of BackboardingBackboarding

The Reality - Blunt The Reality - Blunt TraumaTrauma

1998 Study by Hauswald compared University 1998 Study by Hauswald compared University of New Mexico to University of Malaysia (5yr of New Mexico to University of Malaysia (5yr retrospective study comparing outcomes)retrospective study comparing outcomes)

neurological deterioration was less prevalent in neurological deterioration was less prevalent in patients in Malaysia that were not backboardedpatients in Malaysia that were not backboarded

1999 Perry, et al found that spinal 1999 Perry, et al found that spinal immobilization techniques were ineffective at immobilization techniques were ineffective at limiting spinal motion during simulated vehicle limiting spinal motion during simulated vehicle motion (ie – patient transport)motion (ie – patient transport)

Interesting Interesting StatisticsStatistics

• 1-5 Million patients placed in spinal 1-5 Million patients placed in spinal immobilization per yearimmobilization per year

• 1-3% of severely traumatized patients with 1-3% of severely traumatized patients with cervical fracturecervical fracture

• .4-.7% have unstable cervical fracture.4-.7% have unstable cervical fracture

• 50-70% of patients with unstable cervical 50-70% of patients with unstable cervical fracture have a completed spinal cord injuryfracture have a completed spinal cord injury

The Reality - Penetrating The Reality - Penetrating TraumaTrauma

Journal of Trauma 2006 article studied assault Journal of Trauma 2006 article studied assault victims in Las Angelesvictims in Las Angeles

57,532 assault victims57,532 assault victims

0.41% had cervical fracture0.41% had cervical fracture

GSW’s had 1.35%, Stabbing had 0.11%GSW’s had 1.35%, Stabbing had 0.11%

Precautionary Precautionary ImmobilizationImmobilization

It’s estimated that at least five million patients It’s estimated that at least five million patients are immobilized in the prehospital environment are immobilized in the prehospital environment in the U.S. each year. Most have no complaints of in the U.S. each year. Most have no complaints of neck or back pain or other evidence of spine neck or back pain or other evidence of spine injuryinjury

EMS personnel were not traditionally given EMS personnel were not traditionally given protocols or authority to determine the need for protocols or authority to determine the need for spinal immobilizationspinal immobilization

this was based on false belief that immobilization this was based on false belief that immobilization was always the safest option !!!!!!!!!was always the safest option !!!!!!!!!

Paradigm ShiftParadigm ShiftSome prehospital care providers will admit that Some prehospital care providers will admit that they often immobilize patients without they often immobilize patients without evidence of spine injury because they want to evidence of spine injury because they want to avoid being questioned on arrival at the avoid being questioned on arrival at the emergency departmentemergency department

This dynamic can (and must) change with This dynamic can (and must) change with education and outreacheducation and outreach

ConclusionConclusionthe 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 PhilosophyNew Philosophy

• Spinal immobilization can cause potential harm Spinal immobilization can cause potential harm to the patient and may in some cases delay or to the patient and may in some cases delay or impede life saving care impede life saving care

• It should not be preformed without the proper It should not be preformed without the proper justification justification

• Consider risks of immobilization vs risks of not Consider risks of immobilization vs risks of not immobilizing immobilizing

• You must also consider the time involved in You must also consider the time involved in immobilization and delay of patient transport.immobilization and delay of patient transport.

New Definition of Spinal New Definition of Spinal ImmobilizationImmobilization

• Spinal immobilization will consist of an Spinal immobilization will consist of an appropriately sized cervical collar and appropriately sized cervical collar and securing the patient adequately to the securing the patient adequately to the stretcherstretcher

Adjuncts for Adjuncts for ImmobilizationImmobilization

• These are other tools These are other tools to be used to assist in to be used to assist in moving a patient who moving a patient who is unable or unwilling is unable or unwilling to move due to pain or to move due to pain or injuryinjury

ConsiderationsConsiderations

• If secondary devices are used to assist with If secondary devices are used to assist with patient transport and immobilization the patient transport and immobilization the method selected should:method selected should:

• Minimize gross movement of the spineMinimize gross movement of the spine

• Minimize patient discomfortMinimize patient discomfort

• Allow for adequate airway protectionAllow for adequate airway protection

Purpose of a BackboardPurpose of a Backboard

• Extrication DeviceExtrication Device

• Firm Surface for chest compressionsFirm Surface for chest compressions

Patient Self-ExtricationPatient Self-Extrication• May be allowed if the patient is alert and May be allowed if the patient is alert and

cooperativecooperative

• Patient should be able to assist in limiting gross Patient should be able to assist in limiting gross movement of the spinemovement of the spine

• Apply collar and ask patient to limit bending Apply collar and ask patient to limit bending and rotation of the spineand rotation of the spine

• Assist patient out of vehicle/circumstance to a Assist patient out of vehicle/circumstance to a waiting stretcher placed as close as possible to waiting stretcher placed as close as possible to the patientthe patient

Self Extrication Self Extrication ContinuedContinued

• This option should be reserved for situations This option should be reserved for situations where mechanism of injury is less likely to where mechanism of injury is less likely to produce spinal injury produce spinal injury

• Any patient stating they are in too much pain Any patient stating they are in too much pain to self extricate should be extricated in to self extricate should be extricated in traditional fashion by EMS providers traditional fashion by EMS providers

Patient MonitoringPatient Monitoring

• Any patient who undergoes spinal Any patient who undergoes spinal immobilization should have frequent immobilization should have frequent reassessments of their airway and neurologic reassessments of their airway and neurologic status status

DocumentationDocumentation• Careful documentation should be done Careful documentation should be done

detailing the rationale for the selected method detailing the rationale for the selected method of spinal immobilization or the decision to not of spinal immobilization or the decision to not use spinal immobilization use spinal immobilization

• This documentation will include a detailed This documentation will include a detailed physical exam of the patient’s vertebral physical exam of the patient’s vertebral column, a detailed neurologic exam, an column, a detailed neurologic exam, an assessment of the patient’s mental status and assessment of the patient’s mental status and competency, as well as the presence or competency, as well as the presence or absence of distracting injuries absence of distracting injuries

Who Needs Spinal Who Needs Spinal Immobilization?Immobilization?

• If the answer to either of these questions is If the answer to either of these questions is ‘yes’, the patient should undergo spinal ‘yes’, the patient should undergo spinal immobilization. If the answer to both of these immobilization. If the answer to both of these questions is ‘no’, the patient may be questions is ‘no’, the patient may be transported in a position of comfort. transported in a position of comfort.

• 1 – Is the patient or their exam 1 – Is the patient or their exam unreliable? unreliable?

• 2 – Does the patient have an abnormal 2 – Does the patient have an abnormal spine or neurologic exam? spine or neurologic exam?

Reliable Exam Reliable Exam

• patient must be mentally competent with no signs of patient must be mentally competent with no signs of altered mental status or intoxicationaltered mental status or intoxication

• must not have a distracting injury causing pain that must not have a distracting injury causing pain that would mask spinal tendernesswould mask spinal tenderness

• the patient must have no language barriers the patient must have no language barriers preventing clear communication with the EMS crewpreventing clear communication with the EMS crew

• The patient must not have dementiaThe patient must not have dementia

• The patient must not be someone The patient must not be someone less than 5 years less than 5 years old or greater than 65 years old old or greater than 65 years old who has a who has a significant mechanism of injury. The threshold for significant mechanism of injury. The threshold for significant mechanism of injury is much lower in the significant mechanism of injury is much lower in the elderly. elderly.

Abnormal Spine or Neuro Abnormal Spine or Neuro ExamExam

• pain to palpation of the vertebral column. pain to palpation of the vertebral column.

• any pain in the vertebral column with range of any pain in the vertebral column with range of motion movement. motion movement.

• Do not assess range of motion if the patient has Do not assess range of motion if the patient has tenderness of the vertebral column or already tenderness of the vertebral column or already meets the criteria for spinal immobilization. meets the criteria for spinal immobilization.

• deformities of the spinal column. deformities of the spinal column.

• motor or sensory deficits. motor or sensory deficits.

• tingling in the extremities, even in the presence of tingling in the extremities, even in the presence of intact sensation. intact sensation.

Drowning VictimsDrowning Victims

• should not undergo spinal immobilization should not undergo spinal immobilization unless there is a clear history of trauma unless there is a clear history of trauma discovered in the history or exam discovered in the history or exam

• Spinal immobilization (especially if done in the Spinal immobilization (especially if done in the water) may delay life saving resuscitative water) may delay life saving resuscitative efforts such as quality chest compressions efforts such as quality chest compressions

Penetrating TraumaPenetrating Trauma• immobilization for victims of penetrating immobilization for victims of penetrating

trauma may delay life saving surgical trauma may delay life saving surgical intervention intervention

When to Immobilize When to Immobilize Penetrating TraumaPenetrating Trauma

• Obvious neurologic deficit in the extremitiesObvious neurologic deficit in the extremities

• Significant secondary blunt mechanism of Significant secondary blunt mechanism of injury (ex: fall down the stairs after sustaining injury (ex: fall down the stairs after sustaining a gunshot wound)a gunshot wound)

• PriapismPriapism

• Neurogenic shockNeurogenic shock

• Anatomic deformity to the spine secondary to Anatomic deformity to the spine secondary to the injury the injury

Ambulatory PatientsAmbulatory Patients• Patients who are ambulatory at the scene and Patients who are ambulatory at the scene and

who meet the criteria for spinal immobilization who meet the criteria for spinal immobilization may be assisted to a nearby stretcher and may be assisted to a nearby stretcher and immobilized immobilized

• Ambulatory patients should not be placed on a Ambulatory patients should not be placed on a backboardbackboard

• cervical collar should be applied and they can cervical collar should be applied and they can be secured adequately to the stretcher be secured adequately to the stretcher

Infant Car SeatsInfant Car Seats

• Infants restrained in a rear facing car seat may Infants restrained in a rear facing car seat may be extricated and immobilized in the car seat be extricated and immobilized in the car seat

• They may remain there if they are secure and They may remain there if they are secure and their condition allows their condition allows

Combative PatientsCombative Patients

• Combative patients should be immobilized in a Combative patients should be immobilized in a way that does not provoke increased spinal way that does not provoke increased spinal movement or combativeness movement or combativeness

• These cases should be carefully documented These cases should be carefully documented

New KY State New KY State ProtocolProtocol

Selective Spine Selective Spine ImmobilizationImmobilization

In ConclusionIn Conclusion

• This change has been a long time comingThis change has been a long time coming

• State Protocol can be used by agencies State Protocol can be used by agencies currently using the state protocols, others will currently using the state protocols, others will have to submit protocol for approvalhave to submit protocol for approval

• Local Medical Directors all seem to be Local Medical Directors all seem to be supportivesupportive

• We will establish a new local standard of careWe will establish a new local standard of care

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