Purpose of EMS Selective Spinal Immobilization Guideline • Identify and immobilize 100% of patients at risk for unstable injuries • Identify and NOT immobilize patients who have NO risk for cervical spine injury…
IMPORTANT Message • Mechanism is going to be a crucial decision point in this process. This will rule some people out who previously were boarded and collared. • Supine patients who meet the guidelines for Spine Immobilization will be boarded and collared as usual. Whereas, ambulatory patients who meet the protocol will only be collared.
Cervical Spine Injuries-The Problem • Between 2-4% of Blunt Trauma Patients sustain cervical spine injury • Improvements in EMS systems and ATLS have resulted in increased awareness and practice of cervical immobilization
Why not immobilize everybody? • Immobilization is uncomfortable: increased time immobilized = increased pain, risk of aspiration, vulnerable position, etc... • >800,000 U.S. Patients receive cervical radiography each year • Patient exposure to radiation • >97% of xrays are negative • Cost exceeds $175,000,000 /year
Incidence of SCI • About 50 patients per million population. • 12,000/year are treated while another 4,800 die prehospital. • Male-to-female ratio is approximately 2.5-3.0:1 • About 80% of males with SCI are aged 18-25 years.
Most Common Causes of Adult SCI • 45% - MVC • 20% - Falls • 15% - Sports • 15% - Violence • 5% - other
Mechanism of Injury More than 50% of Spinal cord injuries are single vehicle crashes!
Age Based Considerations • 60% of all SCI in >75 years population are caused by simple falls. • Pediatric incidence varies between 1 – 11%. • 5% will occur in the age group of 0-16 years. • Adolescents: C5-C6 level most often injured • Causes in Children • 0-10 years: falls and pedestrian vs auto • >10 years are same as adult
National Emergency X-Radiography Utilization StudyNEXUS Hypothesis: Blunt trauma victims have virtually no risk of cervical spine injury if they meet all of the following criteria: • No neuro deficit, • Normal Level of alertness • No evidence of ETOH/Tox • No posterior midline tenderness • No other distracting painful injury
NEXUS -Results • 818 patients with fracture identified • All except 8 were identified by clinical decision rule • Sensitivity 99% (95% CI 98-99.6%)
8 Patients Not Identified By NEXUS Rules
The Main Point: • You can’t just decide to “clear” the spine without following a standard of care 100% of the time. No “neck-pain” is not an absolute clearance. • Patients whose spinal cord injuries are missed are directly related to poor assessment, lack of recognition of SCI patterns and lack of knowledge about risk factors correlated to SCI.
Kinematics (Mechanism) • Process of evaluating the forces and motion involved when an accident occurs to determine what injuries may have resulted • Based on fundamental principles of physics described in Newton’s Law
Kinematics of Blunt Spinal Injury • Hyperextension • Hyperflexion • Compression • Rotation • Lateral Stress • Distraction • Axial Loading(diving) • Blunt Trauma • Motor Vehicle Collision • Bicycle Fall • Children: Fall > 3 feet • Adult: Fall from standing height
Mechanism of Injury • Physical manner and forces involved in producing injuries or potential injuries • Valuable tool in determining if the a particular set of circumstances could have caused a spinal injury • Mechanisms likely to produce spinal injuries occur in MVAs, falls, violence, and sports (including diving accidents)
Cervical Spine Injuries • C-spine very flexible • Most frequently injured area of spine • Most injuries at C-5/C-6 level
Thoracic Spine Injuries • T-spine less flexible • Narrow spinal canal • Cord injury occurs with minimal displacement • Common mechanisms • Any cord damage usually complete at this level • Most T-spine injuries occur at T-9/T-10
Lumbosacral Spine Injuries • LS spine flexible nerve roots in roomy spinal canal • May have bony injury w/o cord or nerve root damage • Secondary injury still possible • Neurological injury rare w/ isolated sacral injuries
Spinal Column Injury • Bony spinal injuries may or may not be associated with spinal cord injury • These bony injuries include: • Compression fractures of the vertebrae • Comminuted fractures of the vertebrae • Subluxation (partial dislocation) of the vertebrae • Other injuries may include: • Sprains- over-stretching or tearing of ligaments • Strains- over-stretching or tearing of the muscles
Identification of Mechanism of Injury • Clearly Positive Mechanismspinal immobilization indicated • Clearly Negative Mechanismspinal immobilization not indicated • Uncertain MechanismMOI alone inconclusivefurther assessment required to determine if spinal immobilization necessary
Uncertain MechanismAssessment by Clinical Criteria • Pain/Tenderness Exam • Neurological Exam • Motor Function • Sensory Function • Reliable vs. Unreliable Patient Exams
Examples of Positive Mechanism • Penetrating trauma to head, chest, abdomen, pelvis • Axial loading injury • Rollover with signs of impact • Multiple system injuries • Compressed roof of vehicle • Falls greater than 20 feet
Examples of Positive Mechanism • Death of occupant in same car • Struck by vehicle traveling more than 30 mph • Severe vehicle deformity, intrusion of car >12 inches • Ejection from vehicle
Pain/Tenderness Exam • Spine Pain • Spine Tenderness
Neurological Exam • Motor Function • Sensory Function • Reliable vs. Unreliable Patient Exams
Motor Function • Upper Extremities • Abduction/Adduction • Finger/Hand extension • Lower Extremities • Plantar Flexion • Great Toe Dorsiflexion
Sensory Function • Test sensation at two levels • Must include testing for sensation to pain and light touch at the lateral and medial aspects of each upper extremity and each lower extremity
Sensory Function • Abnormal Sensation- Numbness, weakness, paraesthesia, or ridiculer pain • Pain Sensation- Test ability to distinguish pain from light touch in both upper and lower extremities
Examples of Abnormal Neuro Findings • Paresthesia distal to injury, unilateral or bilateral • Unilateral weakness, motor or sensory findings in limbs • Altered level of consciousness or affect • Any abnormality to pan, temperature or position sense.
Reliable vs. Unreliable Patient Exams INDICATIONS FOR PATIENT EXAM RELIABILITY *NO **YES Acute Stress Reaction (ASR) Calm Agitated, Combative Cooperative Intoxication/Drug Use Sober/No Drug Use Abnormal Mental Status -- Alert & Oriented (Note: be particularly careful assessing mental status in head-injured patients) Distracting Injuries – (painful long bone fractures, significant soft tissue injuries, etc.) Communication Problems -- Language Barrier, mental handicap, etc.
Criteria for High Risk/ Unreliable Patients • GCS ≤ 12 • Pediatric ≤ 12, ≥ Elderly 65 • Alcohol, drug, any mind altering substance use. • Other painful injuries. • Down Syndrome. • Acute stress reaction or severe anxiety. • Shock • History of serious spine problems.
Spinal Immobilization Decision Algorithm RULE 1 “Use algorithm for stable patients with negative or questionable mechanism of injury.”
Spinal Immobilization Decision Algorithm RULE 2 “Any unstable patient or potentially unstable patient with positive mechanism of injury, are to be rapidly extricated and immobilized per regional guidelines and PHTLS recommendations without compromising short scene times.”
Spinal Immobilization Decision Algorithm RULE 3 “Immobilization can be safely deferred when there is a negative mechanism of injury. When the mechanism is questionable or uncertain, clinical criteria are to be used to determine immobilization of the stable patient.”
“Other painful injuries.”Distracting Injuries • These patients have been correlated with missed fractures/ injuries due to the masking effects of sympathetic nervous system stimulation.
Positive or questionable mechanism of injury • POSITIVE: “Positive mechanism” is determined following the State of Connecticut Trauma Protocols and Regulations. (Example: Fall of 25 feet) • S.I. indicated • QUESTIONABLE: “Questionable mechanism” exists where the mechanism of injury is unclear regarding impact and forces involved. (Examples: Minor MVC with minimal vehicle damage; simple fall of less than 5 feet) • S.I. POSSIBLY not indicated, continue with assessment to determine S.I. need.
Positive or questionable mechanism of injury • NEGATIVE: “Negative mechanism” exists when no reasonable possibility of spinal injury is present. (Example: Knee/ankle injury while running with no fall, GSW to arm/leg) • S.I. not indicated • NOTE: These are only baseline principles. All factors, including patient vital signs and symptoms, should be evaluated prior to final determination of need for S.I.
Long backboards may not need to be utilized for spinal immobilization of patients who have been ambulatory after the mechanism of injury before EMS has arrived. Ambulatory patients who require spinal immobilization can be placed in an appropriately sized collar and secured on the ambulance stretcher in the position of comfort while limiting the movement of the neck during the process. Take Home Message
Mechanism is going to be a crucial decision point in this process. This will rule some people out who previously were boarded and collared. • Supine patients who meet the guidelines for Spine Immobilization will be boarded and collared as usual. Whereas, ambulatory patients who meet the protocol will only be collared.
Case Study One • Dispatch • 68 y/o female c/o weakness to arms, unable to get out of car. Car parked in shopping mall parking lot. • Arrival • Pt sitting in drivers seat of car, GCS 15, no distress • Pt states she drove car over concrete parking divider, “really jerking my head” when she drove over 6 inch divider.
Case Study One (cont) • Initial assessment: ABC’s normal, c-spine control initiated • Stable or unstable? • Evaluate MOI • Secondary Assessment • VS normal • No pain on palpation of spine • No deformity palpable • Lower extremities= normal motor or sensory exam • Upper extremities= Good sensation to light touch and sharp touch; but, weak motor function
Case Study One (cont) • Risk/Reliability: Hx of osteoporosis • Treatment: Full immobilization • Reassessment: VS normal, further decrease in motor function of upper extremities, No sensory changes, lower extremities without changes, patient c/o dull pain to neck