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Spinal Immobilization. Erin Burnham, MD - erinburner@gmail.com. To C spine or not to C spine ?. That is the Question!. Framework for Discussion. Who should be immobilized? How should they be immobilized? How can we Assure Quality?. Who should be immobilized?. Goal.

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spinal immobilization
Spinal Immobilization
  • Erin Burnham, MD - erinburner@gmail.com
to c spine or not to c spine
To Cspine or not to Cspine?
  • That is the Question!
framework for discussion
Framework for Discussion
  • Who should be immobilized?
  • How should they be immobilized?
  • How can we Assure Quality?
slide5
Goal
  • Clearing C-spine in the field?
case 78 yo male
Case: 78 yo male
  • An 78 yo male brought in Code-3 by EMS after cardiac arrest. Dispatched for “possible heart attack”.
  • Hx: Had been fishing that morning with son with no complaints. Stood up from recliner chair and collapsed onto ground.
case 78 yo male7
Case: 78 yo male
  • Paramedics found patient apneic, pulseless
  • EKG showed V-fib
  • Patient was successfully defibrillated in field with ROSC.
case 78 yo male8
Case: 78 yo male
  • Pt arrives in ED in NSR, intubated with no spontaneous respiratory effort.
  • He is placed in C-collar in ED because noted to have contusion on forehead.
case 78 yo male9
Case: 78 yo male
  • CT scan of head is normal
  • CT scan of C-spine revealed type II odontoid fracture with displacement
  • EKG and labs unremarkable
case 78 yo male10
Case: 78 yo male
  • Family elects to have patient extubated, and he expires in ED
  • Would pre-hospital immobilization have effected outcome?
  • Medico-legal liability?
case 49 yo male
Case: 49 yo male
  • Motorcycle vs Deer
  • Speed estimated at 45 mph.
  • Patient can’t remember exactly what caused accident, but EMT’s find dead deer nearby.
  • Was wearing full leathers/helmet
  • He was not intoxicated
case 49 yo male12
Case: 49 yo male
  • Only c/o L. Shoulder pain
  • Patient arrives not in spinal immobilization
  • Placed in c-collar in ED
  • L. Scapula fracture, 2 rib fractures and small L. PTX identified
case 49 yo male13
Case: 49 yo male
  • CT head and C-spine obtained
  • CT head is normal
  • C-5 transverse process fracture identified
case 49 yo male14
Case: 49 yo male
  • Fracture is stable and doesn’t effect his outcome
  • He is transferred to a trauma center
  • Uneventful recovery
  • Out windsurfing a few weeks ago
slide15
Goal
  • Clearing C-spine in the field?
  • Provide clear, simple and safe guidelines for prehospital spinal immobilization.
why immobilize
Why immobilize?
  • 253,000 people in US living with spinal cord injuries
  • 12,000 new cases each year
  • In US, cost of MVC related SCI estimated $34.8 billion per year
  • 5 million patients in the US receive spinal immobilization each year
  • Spinal Cord Injury Information Network (www.spinalcord.uab.edu)
epidemiology
Epidemiology
  • 77.8% males
  • Average age of injury is increasing:
    • 28.7 yo in 1970’s
    • 39.5 yo in 2005
  • Spinal Cord Injury Information Network (www.spinalcord.uab.edu)
epidemiology19
Epidemiology
  • MVC - 42%
  • Falls - 27%
  • Violence - 15%
  • Sports - 7.4%
  • Spinal Cord Injury Information Network (www.spinalcord.uab.edu)
why immobilize20
Why immobilize?

Why immobilize?

  • AANS 2001 Guidelines for Pre-Hospital Cervical Spinal Immobilization following trauma:
    • “There is insufficient evidence to support treatment standards”
    • “There is insufficient evidence to support treatment guidelines.”
  • American Association of Neurological Surgeons, 2001
why immobilize21
Why immobilize?

Why immobilize?

  • “It is estimated that 3 to 25% of spinal cord injuries occur after the initial traumatic insult”:
    • During extrication
    • During transit
  • American Association of Neurological Surgeons, 2001
why immobilize22
Why immobilize?

Why immobilize?

    • Over the last 30 years there has been a dramatic improvement in the neurologic status of spinal cord injured patients arriving in the emergency department.
      • 1970’s - 55% complete neurologic lesions
      • 1980’s - 49%
  • American Association of Neurological Surgeons, 2001
why immobilize23
Why immobilize?

Why immobilize?

    • “This has been attributed to the development of Emergency Medical Services initiated in 1971, and the pre-hospital care (including spinal immobilization) rendered by EMS personnel.
      • What about NHTSA?
  • American Association of Neurological Surgeons, 2001
1999 naemsp position paper
1999 NAEMSP Position Paper

INDICATIONS FOR PREHOSPITAL SPINAL IMMOBILIZATION

Robert M. Domeier, MD, for the National Association of EMS Physicians Standards and Clinical Practice Committee

  • http://www.naemsp.org/pdf/spinal.pdf
1999 naemsp position paper25
1999 NAEMSP Position Paper
  • “There have been no reported cases of spinal cord injury developing during appropriate normal patient handling of trauma patients who did not have a cord injury incurred at the time of the trauma.”
  • http://www.naemsp.org/pdf/spinal.pdf
1999 naemsp position paper26
1999 NAEMSP Position Paper
  • “Although early emergency medical literature identified mis-handling of patients as a common cause of iatrogenic injury, these instances have not been identified anywhere in the peer-reviewed literature and probably represent anecdote rather than science.”
  • http://www.naemsp.org/pdf/spinal.pdf
1999 naemsp position paper27
1999 NAEMSP Position Paper
  • Spine immobilization is indicated with a significant mechanism of injury and at least one of following criteria:
    • Altered mental status
    • Evidence of intoxication
    • A distracting painful injury (e.g. Long-bone extremity fracture)
    • Neurologic deficit
    • Spinal pain or tenderness
1999 naemsp position paper28
1999 NAEMSP Position Paper
  • Caveats:
    • Language or communication barriers
    • Extremes of age
    • Difficult to assess intoxication in field
    • Variable interpretation of spinal pain or tenderness
  • http://www.naemsp.org/pdf/spinal.pdf
adverse effects of spinal immobilization
Adverse Effects of Spinal Immobilization
  • Time
  • Compliance
  • Nausea/aspiration
  • Pain/unhappiness
  • Increased MD workup bias
  • Ulcers
  • Impaired ventilation
  • Increased ICP
kwan et al 2004
Kwan, et al 2004

Effects of Prehospital Spinal Immobilization:

A Systematic Review of Randomized Trials

on Healthy Subjects

Irene Kwan, MSc;1 Frances Bunn, MSc2

  • http://pdm.medicine.wisc.edu/Volume_20/issue_1/kwan.pdf
kwan et al 200432
Kwan, et al 2004
  • 2004 Cochrane Review
  • Systematic review of 17/4453 randomized controlled trials comparing types of spinal immobilization devices
  • http://pdm.medicine.wisc.edu/Volume_20/issue_1/kwan.pdf
kwan et al 200433
Kwan, et al 2004
  • Adverse effects of spinal immobilization included:
    • Significant increase in respiratory effort
    • Skin ischemia
    • Pain/discomfort
  • http://pdm.medicine.wisc.edu/Volume_20/issue_1/kwan.pdf
atls 2008
ATLS 2008
  • Several studies have shown correlation between the length of time on a rigid spine board and the development of pressure ulcers.
  • “A paralyzed patient who is allowed to lie on a hard board for more than 2 hours is at high risk for serious decubitus ulcers.”
  • 2008 ATLS Course Manual, 8th edition
increased icp
Increased ICP
  • Cervical collars have been associated with elevations of intracranial pressure (ICP)
    • Prospective study of 20 patients
    • Rigid Philadelphia collar
    • Significant (p = .001) increase in ICP from 176.8 to 201.5 mm H20
  • Kolb, et al, Ann Emerg Med. 1999; 17:135-137
nexus national emergency x radiography utilization study
NEXUS National Emergency X-Radiography Utilization Study
  • Prospective, multi-hospital
  • Cervical spine clearance if no
    • Intoxication
    • Distracting injury
    • Neuro deficit
    • Midline spine tenderness
  • 34,069 at risk for cervical fracture from blunt
    • 818 (2.4%) cervical spine injuries
    • Missed 8 (99% sensitive, 12% specific)
    • Good confidence intervals (98-99.6%)
  • Only 2 injuries deemed clinically significant
  • Hoffman, et al, NEJM, July 13, 2000, Vol. 343, No. 2; p. 94 - 99
pediatric cervical spines
Pediatric Cervical Spines
  • 3065 (9%) of NEXUS patients were <18 years
  • 0.98% cervical spine injury
  • No SCIWORA
  • Decision rule 100% sensitive
  • Confidence intervals 87-100%
  • Viccellio, et al, Pediatrics, Aug 2001, Vol. 108, No. 2
vaillancourt et al 2009
Vaillancourt, et al 2009
  • The Out-of-Hospital Validation of the Canadian C-Spine Rule by Paramedics
  • Ann Emerg Med. 2009;54:663-671
vaillancourt et al 200939
Vaillancourt, et al 2009
  • Prospective cohort study
  • Alert and stable trauma patients
  • Advanced and basic care paramedics interpreted rule
  • All were then immobilized and evaluated in ED
  • Ann Emerg Med. 2009;54:663-671
vaillancourt et al 200941
Vaillancourt, et al 2009
  • 1,949 patients
  • Paramedics classification showed:
    • 100% sensitivity
    • 37.7% specificity
  • Ann Emerg Med. 2009;54:663-671
vaillancourt et al 200942
Vaillancourt, et al 2009
  • Paramedics conservatively misinterpreted the rule in 320 (16.4%)
  • Paramedics were comfortable applying the rule in 1,594 (81.7%)
  • Ann Emerg Med. 2009;54:663-671
vaillancourt et al 200943
Vaillancourt, et al 2009
  • Application of the criteria could have reduced 731 (37.7%) out-of-hospital immobilizations.
  • Ann Emerg Med. 2009;54:663-671
vaillancourt et al 200944
Vaillancourt, et al 2009
  • Conclusion:
    • Paramedics can apply the Canadian C-spine rule reliably without missing any important cervical spine injuries.
  • Ann Emerg Med. 2009;54:663-671
atls 200846
ATLS 2008
  • “Cervical spine injury requires continuous immobilization of the entire patient with a semirigid cervical collar, head immobilization, backboard, tape, and straps before and during transfer to a definitive-care facility.”
  • 2008 ATLS Course Manual, 8th edition
kwan et al 200447
Kwan, et al 2004
  • The following methods were efficacious in restricting movement:
    • Collars
    • Spine boards
    • Vacuum splints
    • Abdominal/torso strapping
  • http://pdm.medicine.wisc.edu/Volume_20/issue_1/kwan.pdf
neutral postion
Neutral Postion
  • The “neutral position” is poorly defined:
    • “The anatomic position of the head and torso that one assumes when standing and looking ahead”
    • 12° of cervical spine extension on lateral radiograph
  • American Association of Neurological Surgeons, 2001
neutral postion49
Neutral Postion
  • “McSwain et al determined that more than 80% of adults require 1.3 cm to 5.1 cm of padding to achieve neutral positioning.”
  • This appears to be a reference to PHTLS text
  • American Association of Neurological Surgeons, 2001
1999 naemsp position paper51
1999 NAEMSP Position Paper
  • “Currently, spinal immobilization is often performed based only on the mechanism of injury without consideration of the patient’s symptoms and physical findings.”
1999 naemsp position paper52
1999 NAEMSP Position Paper
  • “EMS systems adopting procedures for clearance from prehospital spinal immobilization must develop mechanisms for education and quality improvement to ensure safe and appropriate use of clearance protocols.”
slide53
Goal
  • Clearing C-spine in the field?
  • Provide clear, simple and safe guidelines for prehospital spinal immobilization.
quality assurance54
Quality Assurance
  • Protocol should be:
    • Clear
    • Simple
    • Safe
quality assurance55
Quality Assurance
  • System should ensure:
    • Efficacy
    • Compliance
myers et al 2009
Myers et al, 2009
  • Retrospective study
  • 2 gold standards:
    • Radiographic findings
    • Physician clearance without x-ray
  • Myers, et al, Int J Emerg Med 2009; 2:13-17
myers et al 200957
Myers et al, 2009
  • Guideline allows exclusion of spinal immobilization if:
    • No pain, stiffness, soreness or tenderness in the neck or back
    • No alteration in LOC
    • No intoxication
    • No other painful or distracting condition
    • No signs or symptoms of shock
  • Myers, et al, Int J Emerg Med 2009; 2:13-17
myers et al 200958
Myers et al, 2009
  • Included 942 patients
    • 384 did not meet criteria for clearance
      • 36 (9.4%) had fractures
    • 558 patients met criteria for clearance
      • 7 (1.3%) had fractures
  • Myers, et al, Int J Emerg Med 2009; 2:13-17
myers et al 200959
Myers et al, 2009
  • When immobilization was indicated
    • Caregivers were 77.6% compliant
  • Myers, et al, Int J Emerg Med 2009; 2:13-17
myers et al 200961
Myers et al, 2009
  • The median age of the fractures that were immobilized was 48 years
  • The median age of the 7 fractures not immobilized was 82 years
  • An age extreme criteria may enhance this guideline
  • Myers, et al, Int J Emerg Med 2009; 2:13-17
columbia gorge protocol
Columbia Gorge Protocol
  • SPINAL STABILIZATION
    • Trauma patients with the following injuries or signs/symptoms should be treated with full spinal immobilization.
      • Head or facial injury
      • Decreased level of consciousness
      • Head, neck or back pain, consider spinal stabilization.
      • Any patient meeting the trauma system criteria
    • The level of treatment given other patients will be left to the discretion of the senior EMT. The mechanism of injury should be considered in this decision. This protocol is not intended to discourage the use of full spinal immobilization on any patient.
    • Consider padding the upper half of the board for patient comfort if time and circumstances permit.
multnomah county protocol
Multnomah County Protocol
  • Selective Spinal Immobilization
  • Immobilize  using  a  long  spine  board  if  the  patient  has  a  mechanism  with  the  potential  for causing  spinal  injury  and  meets  ANY  of  the  following  clinical  criteria:                      
    • A.  Altered  mental  status.
    • B.  Evidence  of  intoxication.
    • C.  Distracting  pain/injury  (extremity  fracture,  drowning,  etc.).
    • D. Neurologic deficit (numbness, tingling or paralysis)
    • E.  Spinal  pain  or  tenderness.
    • F.  Distracting  situation  (communication  barrier,  emotional  distress,  etc.).
state of jefferson protocol
State of Jefferson Protocol

SPINAL IMMOBILIZATION

First Responder, EMT-B, EMT-I, EMT-P

INDICATIONS:

Patients with a risk of cervical, thoracic, or lumbar spine injury based on mechanism of injury and findings of spinal pain, tenderness or neurologic abnormality.

PROCEDURE:

For actual or suspected penetrating trauma of the spine,then spinal immobilization indicated

For blunt trauma with mechanism for spinal cord injury, thenspinal immobilization if any of the following are answered “yes”:

jackson county protocol
Jackson County Protocol

If any answer is “yes”, then spinal immobilization indicated.

case 78 yo male67
Case: 78 yo male
  • Age < 10 years or > 65 years
  • Altered mental status or loss of consciousness
  • Evidence of intoxication
  • Significant mechanism of injury, such as high speed motor vehicle crash, axial loading, rollover motor vehicle crash, fall from greater than standing height
  • Distracting injury, such as significant fracture or laceration
  • Neurologic deficit
  • Midline spine pain
  • Midline spine tenderness
  • EMT suspects spinal cord injury based on mechanism, history or exam findings
  • Pain with active neck rotation or active ROM of neck rotation < 45°
case 49 yo male68
Case: 49 yo male
  • Age < 10 years or > 65 years
  • Altered mental status or loss of consciousness
  • Evidence of intoxication
  • Significant mechanism of injury, such as high speed motor vehicle crash, axial loading, rollover motor vehicle crash, fall from greater than standing height
  • Distracting injury, such as significant fracture or laceration
  • Neurologic deficit
  • Midline spine pain
  • Midline spine tenderness
  • EMT suspects spinal cord injury based on mechanism, history or exam findings
  • Pain with active neck rotation or active ROM of neck rotation < 45°
jackson county protocol69
Jackson County Protocol

If any answer is “yes”, then spinal immobilization indicated.

discussion71
Discussion
  • Who should be immobilized?
  • How should they be immobilized?
  • How can we Assure Quality?