1. EMS Spinal Assessment and Precautions
This presentation in combination with a second presentation “Spinal Precautions” is designed to provide general rationale and guidance for the upcoming change to the Michigan Spinal Injury Assessment Protocol and Spinal Precautions Procedure. This first presentation was adapted from a presentation prepared by Chelsea White.
Adapted from a presentation prepared by
Chelsea C. White IV, MD, NREMT-P
Medical Director, Bernalillo County Fire Department
Robert M. Domeier, MD, EMS Medical Director,
Washtenaw/Livingston Medical Control Authority

2. Latest Spinal Injury Guidelines
In July, 2013, NAEMSP and ACS-COT released a joint position paper on “EMS Spinal Precautions and the Use of the Long Backboard”
Highlights:
Utilization of backboards for spinal immobilization during transport should be judicious, so that the potential benefits outweigh the risks
In July of 2013, the National Association of EMS Physicians (NAEMSP) and the American College of Surgeons – Committee on Trauma (ACS-COT) released a joint position paper titled “EMS Spinal Precautions and the Use of the Long Backboard” Some of the highlights of the position statement include: Highlights……

3. Latest Clinical Guidelines
Highlights:
Patients with penetrating trauma to the head, neck, or torso and no evidence of spinal injury should not be immobilized on a backboard
Spinal precautions can be maintained by application of a rigid cervical collar and securing the patient to the EMS stretcher, and may be most appropriate for:
Patients who are found to be ambulatory at the scene
Patients who must be transported for a protracted time, particularly prior to interfacility transfer
Other important points include these: ….

4. What do we do with this?
Now that reasonable literature driven guidelines are available, What do we do with this?

5. Backboards have been a part of EMS since the beginning!
Spinal immobilization a key feature of early Emergency Medical Technician training
Backboarding has been the tool used for spinal immobilization since the beginning of EMS. Some of the first texts used for EMS provider training also included the use of the long backboard for spinal immobilization as part of the curriculum items taught to those providers.

6. 1960s: Growing Awareness of Spinal Injuries
“The most frequently mishandled injuries, made worse by hasty and rough movement from a vehicle or other accident scene, are fractures of the spine and the femur.”
J.D. Farrington, MD, from DEATH IN A DITCH, American College of Surgeons, 1967
So where did Boarding come from in the first place?
Early statements made about the presumed dangers while moving patients became dogma, without any supporting evidence or research. This statement from “Death in a Ditch” clearly states that mishandling of patients can lead to worsening of injuries such as spine fracture. The statement also implies that this type of mishandling occurs frequently.

7. Early Spinal Injury Research
A 1963 survey of a large series of patients with fatal injuries treated at the Edinburgh Royal Infirmary showed that 25% of fatal complications occurred during the period between the accident and arrival in the ED
“A community depends on the expertise of its emergency personnel to correctly manage high risk crises and potentiate recovery”
This similar 1963 statement was taken by several papers at the time to imply that up to 25% of spine injuries worsened because of improper EMS packaging and handling.

8. Early Spinal Injury Research
A 1965 retrospective study of 958 spinal cord injury patients in Toronto attempted to quantify serious cord damage due to “inept handling of the patients”
Only 29 patients (3%) had “incontrovertible” evidence of delayed paralysis, attributed to either pre- or in-hospital inept handling
Authors suspected but could not prove that “a larger number undoubtedly suffered this fate”
Geisler in 1965, reported only a small number of patients with delayed paralysis after injury. He questioned, in effect, whether deterioration happened at all. Despite this second statement, the first was incorporated into the thinking of the time. Quoted numbers for deterioration of spine injured patients related to poor EMS care became 3 – 25% of these spine injured patients.

9. Birth of Spinal Immobilization
In 1966, USAF Col. L. C. Kossuth first described the use of the long backboard to “move a victim from the vehicle with a minimum of additional trauma”
Such movement was to occur with “due regard to maximum gentleness”
In 1966, Kossuth described the use of the long backboard. Over time it became the standard method for maintaining spinal immobilization. Spinal immobilization was the standard method used for maintaining spinal precautions. Not only in EMS, but also in the hospital, the long backboard was used to maintain spinal precautions well into the patient’s hospitalization, particularly in patients who were actually found to have a spine injury.

10. ENDANGERED!
Like the hearse ambulance and Pneumatic Anti Shock Garments (PASG), also known as MAST pants, long backboards used for spinal immobilization during transport, having become so universal, are now also an endangered species in EMS. What has led us to decide that use of a long backboard to maintain spinal precautions during transport is not such a good idea? What follows is a discussion of the evolution of thinking in this area.

11. Backboards Cause Pain
1989 study of 170 trauma victims eventually discharged from a major ED showed a significant reduction in c- and l- spine pain when patients were allowed off the boards
21% had cervical P/T on the board but not off
suggested that the immobilization process or the boards themselves cause pain that otherwise would not be there
1993 study caused 100% of 21 healthy volunteers to report pain within 30 minutes of being strapped to a backboard
Headache, sacral, lumbar, and mandibular pain most common
There are numerous studies that discuss pain being caused by the backboard. A 1989 study found more pain and tenderness when a patient was evaluated on a board compared to being evaluated while not on a board. Pain caused by the backboard comes on quickly. The pain induced by backboards can increase the number of x-rays and CT scans performed during patient evaluation extending emergency department evaluation time and increasing cost.

12. Backboards Cause Pressure Sores
A prospective study at Charity Hospital 1988 of the association between immobilization in the immediate postinjury period and the development of pressure ulcers in spinal cord-injured patients
Time on the spinal board was significantly associated with ulcers developing within 8 days
Pain is an indicator of tissue distress. In 1988, it was reported that there were more frequent pressure sores on patients in which a backboard was used for spinal immobilization.

13. Backboards Cause Pressure Sores
A 1995 study at Methodist Hospital of Indiana measured the interface (contact) pressures over bony prominences of 20 patients on wooden backboards over 80 minutes
Interface pressure > 32 mm Hg causes capillaries collapse, resulting in ischemia and pressure ulceration.
This study measured mean interface pressures as high as 149 mm Hg at the sacrum, 59 mm Hg at occiput, and 51 mm Hg at heels
Direct measurements of pressures at the interface between the skin and wooden backboard give us the mechanisms for the development of pain and pressure sores related to being immobilized with a wooden backboard.

14. Backboards Create Respiratory Compromise
1987 study at Beaumont Hospital of healthy, backboarded males concluded that backboard straps significantly decrease pulmonary function
Similar study 1999 showed 15% respiratory restriction in backboarded adult subjects
Pediatric study in 1991 showed decreased FVC in children due to backboard straps
Other studies reported respiratory compromise in patients and volunteers strapped to backboards.

15. 5 year retrospective chart review at University of New Mexico and University of Malaysia hospitals
All 454 patients with acute spinal cord injuries included during the 5 year study period
None of the 120 U. Malaysia patients were immobilized
All 334 U. of NM patients were immobilized in the field
Hospitals and treatment otherwise equivalent
Results: 2x MORE neurologic disability in the University of New Mexico patients
Hauswald, in a 1998 study comparing EMS practice in Malaysia where no trauma patients are immobilized with a board, compared to patients in New Mexico where nearly all trauma patient are immobilized. There were twice the neurologic injuries in the patients treated in New Mexico compared with those treated in Malaysia. Injuries and hospital treatment were otherwise equivalent.

16. How well do we immobilize anyway?
Convenience sample of 50 low acuity backboarded subjects at one Level 1 ED
30% had at least 1 point where a strap or tape did not secure the head
70% had 1 strap with >4 cm slack
12% had all 4 straps with >4 cm slack
“at 4 cm, movement in any direction along the board is both possible and probable”
A well secured head and mobile body creates moment arm about the neck
One of the perceived benefits of using the backboard to maintain spinal precautions is to keep the patient’s spine immobilized by splinting it with the board. However the board in not very good at actually immobilizing the body of the patient because of the inability to firmly secure the patient to the board. Combine this with the fact that we are very good at immobilizing the patient’s head and potential problems become evident. With an anchored head and a mobile body it is clear that the spinal immobilization procedure as practiced todday might actually cause unwanted force to the cervical spine who’s effect is unknown but could be harmful.

17. Backboards don’t make patients lie still
A violent or agitated patient is going to fight against a backboard, threatening his/her spine
A cooperative patient is going to lie still when asked (or if it hurts to move), regardless of a backboard or straps
In addition, unless the patient is cooperative, the current method might exacerbate movement of the spine during transport related to the patient fighting the immobilization.
So to wrap up this section, over the years, the backboard has been shown to have several down sides. There has also never been a study which demonstrated patient benefit with the use of the long backboard.

18. C-Spine imaging in the ED
By the late 1980s, physicians realized that some patients with neck pain did not need x-rays to rule out spine injury
Several studies showed that patients could be “clinically cleared” without exposing them to radiation
Emergency department treatment of spine injury patient has been well studied. Initially all patients brought in on backboards were x-rayed in many centers. However over time it became clear that some simple rules would reliably determine which set of patients did not need x-rays and could be cleared clinically. These patients could be removed from immobilization without X-rays to clear the spine.

19. NEXUS and Canadian C-Spine rules
These were the two major studies showing the safety of clinical spine clearance by emergency physicians
NEXUS = National Emergency X-Radiography Utilization Group, formed to reduce patient exposure to x-rays
Canadian C-Spine rule developed for similar reasons
Two significant rules were developed for ED care: NEXUS, the Canadian C-spine rule. In practice, many use a combination of these rules to clear the spine in the ED.

20. NEXUS used these 5 criteria, the presence of any of these would trigger radiograph, those that met all the criteria would not need radiography.

21. The Canadian rule is more cumbersome to use
The Canadian rule is more cumbersome to use. Many ED physicians now use a combination of the NEXUS rule with the > 65 rule from Canadian C-Spine to determine which patients need radiographic clearance.

22. Selective Spinal Immobilization
Multiple studies in the late 1990s showed the safety of field spinal clearance by EMS providers
These studies showed that EMS providers were able to apply NEXUS and CCR criteria in the field
Goal was to reduce the amount of patients transported on backboards
Similar to what was going on in the ED. EMS research was done which confirmed the safety of the use of similar criteria for selective immobilization. Patients who met criteria could be transported without spinal precautions, which means without a backboard.

23. This REDUCED backboard use
Backboard use has decreased significantly
BUT, patients with positive spinal assessments still ride on backboards
Many of these patients do not actually have spinal injury
Selective immobilization reduced backboard use by approximately 40% compared to immobilization based on mechanism alone. Even with this change, only approximately 3 percent of trauma patients placed on backboards actually had any type of spine injury.

24. Goal: protect unstable spine fractures without causing new problems
Backboards have been proven to cause:
Pain
Pressure sores
Respiratory compromise
Backboards have NOT been shown to prevent:
Spinal movement
Further neurologic injury
Patients left on boards whether injured or not are subject to the downsides of backboards. This, despite the fact that the backboard has never been shown to prevent spinal movement, worsening of, or development of neurologic injury.

25. Recommendation
Best available evidence supports removing patients from backboards as soon as possible, even if spinal injury is suspected
This already happens in most EDs shortly after a backboarded patient arrives
Given the similarities between an ambulance cot and an ED cot, patients with suspected spinal injury should be removed from the backboard once safely on the ambulance cot
The recommendation from NAEMSP and the ACS-COT is to remove patients from backboard as soon as possible. This practice is the current state of the art in the ED. Patients brought in on backboards are removed at the first log roll independent of the concern for injury. Patients are selectively radiographed once removed from the backboard. Similarly it is now reasonable for trauma patients to be removed from a backboard, if used for extrication, once the patient is safely on the ambulance cot.

26. How do we protect the spine…
…of a patient who MAY have a spine injury…
Even though we will not be using a backboard to maintain spinal precautions, we will still maintain spinal precautions when indicated by placing the patient in a collar and a position of comfort on the padded ambulance cot. By maintaining spinal precautions using the ambulance cot we can protect the spine as best possible without the downside risks of the backboard. So how will we be doing this?
…without the risks of a backboard?

27. NEW Michigan Protocol for Spine Injury Assessment:
This is the new protocol for Spinal Injury Assessment. It is nearly identical to the old, and refers providers to the Spinal Precautions Procedure for patient who have a positive spinal injury assessment or are over 65 with a significant mechanism of injury and a negative injury assessment. This mechanism, for the patient over 65, may be as simple as a fall with a head bonk mechanism. Let’s look at key components of the protocol.

28. If mechanism exists for spinal injury:
Examples:
Fall
Motor vehicle crash
Assault with significant head, neck, or back trauma
Anything else that could cause spinal injury
The first step is to assess the mechanism of injury. Those without a significant mechanism do not need a spinal injury assessment. Examples of significant mechanisms includes these:…..
This is not new, the Spinal Injury Assessment has been used for selective immobilization determination previously. For a patient with a significant mechanism, assess the patient for criteria that warrant the use of Spinal Precautions.

29. Perform Spinal Assessment
6.A-C. Evaluate if the patient can give a reliable exam: Look for:
Are they altered?
Are they intoxicated?
Are they distracted by other injury?
The first three items in the assessment: altered mental status, intoxication or distracting injury are used to determine if the patient can give a reliable exam. If the patient is un-reliable, spinal precautions are indicated. Again not new.

30. Perform Spinal Injury Assessment
Any unexplained focal motor or sensory neurologic deficit
Pain or tenderness in posterior midline over spine
In the reliable patient, exams should be performed to assess for neurologic deficit, spinal pain or tenderness. Not New.

31. Positive Spinal Assessment
If either of these are present, spinal precautions should be maintained. If none of the criteria are present the patient has a negative spinal injury assessment. All patients with a negative assessment do not need spinal precautions. The exception to this is the patient over 65 with a mechanism of injury. These patients should have a collar placed and transport should be done maintaining spinal precautions. This is also not new.

32. POSITIVE SPINAL ASSESSMENT means there is a POSSIBILITY for SPINE and/or SPINAL CORD INJURY Spinal Precautions Procedure should be followed
The key point of the Spinal Injury Assessment protocol is that for all patients with a positive spinal injury assessment there is a possibility for spine and/or spinal cord injury and the Spinal Precautions Procedure should be followed.

33. Michigan Spinal Precautions Procedure
This is the new Michigan Spinal Precautions Procedure. This protocol is completely changed from the previous version. It starts with Indications & General Guidance. Specific Techniques follows and has sections for Cervical collars, self-extrication procedure, emergency patient removal, long extrication device, log roll procedure and spinal precautions.

34. Michigan Spinal Precautions Procedure
The final section is special considerations. Let’s look at the protocol in detail.

35. Spinal Precautions Procedure
Indications & General Guidance
1. Refer to the Spinal Injury Assessment Protocol. Patients with a positive spinal injury assessment should have spinal precautions maintained during transport.
2. Major trauma patients who require extrication should have spinal precautions maintained using an extrication device (long backboard or equivalent) during extrication. If sufficient personnel are present, the patient may be log rolled from the extrication device to the ambulance cot during loading of the patient.
3. Patients may remain on the extrication device if the crew deems it safer for the patient considering stability, time and patient comfort considerations. This decision will be at the discretion of the crew.
Notes:
1. Patients with a positive spinal injury assessment should have spinal precaution maintained
2. Log roll patients to the ambulance cot when possible
3. EMS crews may keep the patient on the extrication device for transport as needed. It may be quicker to log roll the patient onto the ambulance cot than to secure the patient to the extrication device (backboard) and then the cot.
INSTRUCTOR NOTE: Read each of the points on the left. Follow with the notes on the right in which some are just reiterations of the procedure items on the left and some provide additional clarification to the procedure points.
The goal is to not transport patients on a backboard when possible. Patients may be transported on an extrication device when necessary due to patient condition and the presence of other more critical patient care priorities. It may be quicker to log roll the patient off the board than to secure the patient to the board and then the ambulance cot. Do not tape the patient’s head to the extrication device or the ambulance cot.

36. Spinal Precautions Procedure
Indications & General Guidance
4. Patients with penetrating traumatic injuries do not require spinal precautions
unless a focal neurologic deficit is noted on the spinal injury assessment.
5. An ambulatory patient with a positive spinal injury assessment should have an
appropriately sized cervical collar placed. Place the patient directly on the ambulance cot in a position of comfort, limiting movement of the spine during the
process.
6. Patients, who are stable, alert and without neurological deficits may be allowed to self-extricate to the ambulance cot after placement of a cervical collar. Limit movement of the spine during the process.
Notes:
4. Penetrating trauma patients do not require spinal precautions. If a neurologic deficit is noted maintain spinal precautions but no backboard is needed.
5. For ambulatory patients with a positive assessment place a collar and put the patient on the ambulance cot. No standing takedowns.
6. Patients may self-extricate when possible.
Patients who self extricate have less cervical motion than when extricated by rescuers.
INSTRUCTOR NOTE: Read each of the points on the left. Follow with the notes on the right in which some are just reiterations of the procedure items on the left and some provide additional clarification to the procedure points.
Self extrication is new. It has been demonstrated that a patient who can self extricate has less cervical motion than patient’s extricated manually by rescuers.

37. Spinal Precautions Procedure
Indications & General Guidance
7. Patients over the age of 65 with a mechanism of injury with the potential for causing cervical spine injury will have a cervical collar applied even if the spinal injury clinical assessment is negative.
Notes:
7. Place the patient over 65 with a potential mechanism and negative injury assessment in a collar in a position of comfort
Why?
Our spinal assessment tool – the same one we have used for years to decide whether or not to backboard – is not 100% accurate (but it is very close)
Most of the “false negatives” are in patients >65
INSTRUCTOR NOTE: Read each of the points on the left. Follow with the notes on the right in which some are just reiterations of the procedure items on the left and some provide additional clarification to the procedure points.
Patients over 65 with a mechanism should have a collar placed and spinal precautions maintained independent of the results of the spinal injury assessment. This is based on the Canadian C-spine rules recommending radiographic clearance in those 65 and older and the results of assessment of the currently used selective immobilization protocol in which the only significant missed injuries are in patients 65 and older with a mechanism of injury which could potentially cause injury.

38. Spinal Precautions Procedure
Specific Techniques
1. Cervical Collars
A. Cervical collar should be placed on patient prior to patient movement, if possible.
B. If no collar can be made to fit patient, towel, blanket rolls, head block or similar device may be used to support neutral head alignment.
C. The cervical collar may be removed if interfering with airway management or airway placement, or if causing extreme patient distress.
2. Self-Extrication Procedure
A. Patients, who are stable, alert and without neurological deficits may be allowed to self-extricate to the ambulance cot after placement of a cervical collar.
B. Limit movement of the spine during the process.
3. Emergency Patient Removal
A. Indicated when scene poses an imminent or potential life threatening danger to patient and/or rescuers, (e.g. vehicle or structure fire).
B. Remove the patient from danger while best attempt is made to maintain spinal precautions.
C. Rapid Extrication is indicated when patient condition is unstable (i.e.: airway or breathing compromise, shock, unconsciousness, or need for immediate intervention).
4. Long Extrication Device (e.g. long Backboard, scoop stretcher, basket stretcher)
A. Indicated when patient requires spinal precautions and the patient condition prevents self-extrication.
B. Patient's head and cervical spine should be manually stabilized.
C. Rescuers should place the patient in a stable, neutral position where space is created to place backboard or other long extrication device in position near the patient.
D. Move the patient to supine position on the long extrication device.
E. The patient is secured to the device with torso straps applied before head stabilization.
F. Head stabilization material should be placed to allow for movement of the lower jaw to facilitate possible airway management.
G. The extrication device is used to move the patient to the ambulance cot.
INSTRUCTOR NOTES: Go through each item in the Specific Techniques Procedure. These will be supplemented by the second presentation.

39. Spinal Precautions Procedure
Specific Techniques
5. Log Roll Procedure
A. Cervical collar should be placed when indicated.
B. Place the backboard or equivalent behind the patient.
C. Patient is log rolled, maintaining neutral alignment of spine and extremities.
D. Log roll procedure requires 2 or more personnel in contact with the patient.
E. If log roll is not possible, patient should be moved to board or equivalent while attempting to maintain neutral alignment spinal precautions.
F. Patient is secured to the backboard or equivalent for movement to the ambulance cot.
G. Head stabilization materials such as foam pads, blanket rolls may be used to prevent lateral motion. Pad under the head when feasible.
H. If sufficient personnel are present, the patient should be log rolled from the extrication device to the ambulance cot during loading of the patient.
I. When log roll on to the ambulance cot is impractical, secure the patient to the extrication device and ambulance cot for transport.
6. Spinal Precautions
A. Once the patient is placed on the ambulance cot, if no extrication device is still in place, secure the patient with seatbelts in a supine position, or in position of comfort if a supine position is not tolerated.
B. Head may be supported with head block or similar device to prevent rotation if needed. Padding should be placed under the head when practical. Do not tape the head to the ambulance cot.
INSTRUCTOR NOTES: Go through each item in the Specific Techniques Procedure. These will be supplemented by the second presentation.

40. Spinal Precautions Procedure
Special Considerations
1. Hypoventilation is likely to occur with spinal cord injury above the diaphragm.
Quality of ventilation should be monitored closely with support offered early.
2. Spinal/neurogenic shock may result from high spinal cord injury. Monitor patient for signs of shock. Refer to Shock Protocol.
3. Spinal precautions in the patient wearing a helmet should be according to the
Helmet Removal Procedure.
4. Manual spinal precautions in the obtunded patient must be initiated and continued until the patient is secured to the ambulance cot.
5. Patients who are markedly agitated, combative or confused may not be able to follow commands and cooperate with minimizing spinal movement. Rigid
immobilization should be avoided if it contributes to patient combativeness.
Patients may remain on the backboard if the crew deems it safer for the patient,
and this will be at the discretion of the crew.
INSTRUCTOR NOTES: Go through each item in the Special Considerations Section of the Procedure. These items serve as clarification for special circumstances.

41. Spinal Precautions Procedure
Special Considerations
6. Manual in line stabilization must be used during any procedure that risks head or neck movement, such as endotracheal intubation. If manual cervical stabilization is hampering efforts to intubate the patient, the neck should be allowed to move as needed to secure the airway. An unsecured airway is a greater danger to the patient than a spinal fracture.
7. Document spinal precautions techniques utilized.
8. Document the patient’s neurologic status before and after establishing spinal
precautions when possible.
9. Pediatric Patients and Car Seats:
a. Infants restrained in a rear-facing car seat may be immobilized and extricated in the car seat. The child may remain in the car seat if the immobilization is secure and his/her condition allows (no signs of respiratory distress or shock).
b. Children restrained in a car seat (with a high back) may be immobilized and extricated in the car seat; however, once removed from the vehicle, the child
should have spinal precautions maintained as for an adult.
c. Children restrained in a booster seat (without a back) need to be extricated and immobilized following standard procedures.
INSTRUCTOR NOTES: Go through each item in the Special Considerations Section of the Procedure. These items serve as clarification for special circumstances.

42. Backboarding ≠ “Spinal Precautions”
Our practice is to still maintain spinal precautions for patients at risk for spinal injury. However, spinal precautions is no longer synonymous with spinal immobilization with a backboard. Spinal immobilization is no longer the key to treatment of these patients. Maintaining spinal precautions is now the key.

43. Backboards are an EXTRICATION TOOL
Backboards are still valuable tools for patient extrication and movement. Maintaining spinal precautions is key although the use of the backboard should be minimized to prevent the downsides caused by their use during transport.

44. Remember to REMIND hospital staff of potential spine injury
Once at the hospital, make sure to inform the ED staff of the results of the spinal injury assessment. They need to know whether the patient is being maintained in spinal precautions or was felt to have a negative assessment.

45. Questions?