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Selective Spine Immobilization Training Program. REASONS FOR NEW GUIDELINE.

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Presentation on theme: "Selective Spine Immobilization Training Program. REASONS FOR NEW GUIDELINE."— Presentation transcript:

1 Selective Spine Immobilization Training Program


3 PURPOSE OF EMS SELECTIVE SPINAL IMMOBILIZATION GUIDELINE lIdentify and immobilize 100% of patients at risk for unstable injuries lIdentify and NOT immobilize patients who have NO risk for cervical spine injury…

4 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. 5/31/20144

5 CERVICAL SPINE INJURIES- THE PROBLEM lBetween 2-4% of Blunt Trauma Patients sustain cervical spine injury lImprovements in EMS systems and ATLS have resulted in increased awareness and practice of cervical immobilization

6 WHY NOT IMMOBILIZE EVERYBODY? l Immobilization is uncomfortable: increased time immobilized = increased pain, risk of aspiration, vulnerable position, etc... l >800,000 U.S. Patients receive cervical radiography each year l Patient exposure to radiation l >97% of xrays are negative l Cost exceeds $175,000,000 /year

7 INCIDENCE OF SCI lAbout 50 patients per million population. l12,000/year are treated while another 4,800 die prehospital. lMale-to-female ratio is approximately :1 lAbout 80% of males with SCI are aged years.


9 MOST COMMON CAUSES OF ADULT SCI l45% - MVC l20% - Falls l15% - Sports l15% - Violence l5% - other


11 AGE BASED CONSIDERATIONS l60% of all SCI in >75 years population are caused by simple falls. lPediatric incidence varies between 1 – 11%. 5% will occur in the age group of 0-16 years. Adolescents: C5-C6 level most often injured lCauses in Children 0-10 years: falls and pedestrian vs auto >10 years are same as adult

12 NATIONAL EMERGENCY X-RADIOGRAPHY UTILIZATION STUDY NEXUS Hypothesis: Blunt trauma victims have virtually no risk of cervical spine injury if they meet all of the following criteria: lNo neuro deficit, lNormal Level of alertness lNo evidence of ETOH/Tox lNo posterior midline tenderness lNo other distracting painful injury

13 NEXUS -RESULTS l818 patients with fracture identified lAll except 8 were identified by clinical decision rule lSensitivity 99% (95% CI %)

14 8 Patients NotIdentified By NEXUS Rules

15 THE MAIN POINT: You cant 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.


17 KINEMATICS (MECHANISM) lProcess of evaluating the forces and motion involved when an accident occurs to determine what injuries may have resulted lBased on fundamental principles of physics described in Newtons Law

18 KINEMATICS OF BLUNT SPINAL INJURY lHyperextension lHyperflexion lCompression lRotation lLateral Stress lDistraction l Axial Loading(diving) l Blunt Trauma l Motor Vehicle Collision l Bicycle Fall l Children: Fall > 3 feet l Adult: Fall from standing height

19 MECHANISM OF INJURY lPhysical manner and forces involved in producing injuries or potential injuries lValuable tool in determining if the a particular set of circumstances could have caused a spinal injury lMechanisms likely to produce spinal injuries occur in MVAs, falls, violence, and sports (including diving accidents)

20 CERVICAL SPINE INJURIES lC-spine very flexible lMost frequently injured area of spine lMost injuries at C-5/C-6 level

21 THORACIC SPINE INJURIES lT-spine less flexible lNarrow spinal canal lCord injury occurs with minimal displacement lCommon mechanisms lAny cord damage usually complete at this level lMost T-spine injuries occur at T-9/T-10

22 LUMBOSACRAL SPINE INJURIES lLS spine flexible nerve roots in roomy spinal canal lMay have bony injury w/o cord or nerve root damage lSecondary injury still possible lNeurological injury rare w/ isolated sacral injuries

23 SPINAL COLUMN INJURY lBony spinal injuries may or may not be associated with spinal cord injury lThese bony injuries include: Compression fractures of the vertebrae Comminuted fractures of the vertebrae Subluxation (partial dislocation) of the vertebrae lOther injuries may include: Sprains- over-stretching or tearing of ligaments Strains- over-stretching or tearing of the muscles


25 IDENTIFICATION OF MECHANISM OF INJURY Clearly Positive Mechanism spinal immobilization indicated Clearly Negative Mechanism spinal immobilization not indicated Uncertain Mechanism MOI alone inconclusive further assessment required to determine if spinal immobilization necessary

26 UNCERTAIN MECHANISM ASSESSMENT BY CLINICAL CRITERIA lPain/Tenderness Exam lNeurological Exam Motor Function Sensory Function lReliable vs. Unreliable Patient Exams

27 EXAMPLES OF POSITIVE MECHANISM l Penetrating trauma to head, chest, abdomen, pelvis l Axial loading injury l Rollover with signs of impact l Multiple system injuries l Compressed roof of vehicle l Falls greater than 20 feet

28 EXAMPLES OF POSITIVE MECHANISM l Death of occupant in same car l Struck by vehicle traveling more than 30 mph l Severe vehicle deformity, intrusion of car >12 inches l Ejection from vehicle

29 PAIN/TENDERNESS EXAM lSpine Pain lSpine Tenderness

30 NEUROLOGICAL EXAM lMotor Function lSensory Function lReliable vs. Unreliable Patient Exams

31 MOTOR FUNCTION lUpper Extremities Abduction/Adduction Finger/Hand extension lLower Extremities Plantar Flexion Great Toe Dorsiflexion


33 SENSORY FUNCTION lTest sensation at two levels lMust include testing for sensation to pain and light touch at the lateral and medial aspects of each upper extremity and each lower extremity

34 SENSORY FUNCTION lAbnormal Sensation- Numbness, weakness, paraesthesia, or ridiculer pain lPain Sensation- Test ability to distinguish pain from light touch in both upper and lower extremities

35 EXAMPLES OF ABNORMAL NEURO FINDINGS l Paresthesia distal to injury, unilateral or bilateral l Unilateral weakness, motor or sensory findings in limbs l Altered level of consciousness or affect l Any abnormality to pan, temperature or position sense.

36 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.

37 CRITERIA FOR HIGH RISK/ UNRELIABLE PATIENTS l GCS 12 l Pediatric 12, Elderly 65 l Alcohol, drug, any mind altering substance use. l Other painful injuries. l Down Syndrome. l Acute stress reaction or severe anxiety. l Shock l History of serious spine problems.


39 SPINAL IMMOBILIZATION DECISION ALGORITHM RULE 1 Use algorithm for stable patients with negative or questionable mechanism of injury.

40 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.

41 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.

42 OTHER PAINFUL INJURIES. DISTRACTING INJURIES These patients have been correlated with missed fractures/ injuries due to the masking effects of sympathetic nervous system stimulation.

43 POSITIVE OR QUESTIONABLE MECHANISM OF INJURY lPOSITIVE: Positive mechanism is determined following the State of Connecticut Trauma Protocols and Regulations. (Example: Fall of 25 feet) S.I. indicated lQUESTIONABLE: 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.

44 POSITIVE OR QUESTIONABLE MECHANISM OF INJURY lNEGATIVE: 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 lNOTE: 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.

45 TAKE HOME MESSAGE 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.

46 5/31/ 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.

47 Case Studies

48 Case Study One lDispatch –68 y/o female c/o weakness to arms, unable to get out of car. Car parked in shopping mall parking lot. lArrival –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.

49 Case Study One (cont) lInitial assessment: ABCs normal, c-spine control initiated lStable or unstable? lEvaluate MOI lSecondary 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

50 Case Study One (cont) lRisk/Reliability: Hx of osteoporosis lTreatment: Full immobilization lReassessment: VS normal, further decrease in motor function of upper extremities, No sensory changes, lower extremities without changes, patient c/o dull pain to neck

51 Case Study One (cont) lDiagnosis: Central Cord Syndrome lDiscussion –Hyperextension mechanism –Swelling of central cord –Most common type of cord injury –Loss of motor and sensory function below level of cord injury with greater loss in arms than legs

52 Case Study Two lDescription of case: A 53 year old male was involved in a moderate- speed MVA. He was driver of car that rear-ended another car. Both cars have serious fender damage. The hood of your patients car is pushed in and bent. the windshield is intact. He states he was wearing his seat belt. He complains of some shoulder soreness. He is sitting in his car when you arrive.

53 Case Study Two (cont) lInitial Assessment: ABCs are normal. Cervical spine stabilization is manually obtained because of the appearance of the cars. lDecide Stability of patient: Stable lEvaluate MOI: Questionable. lSecondary Assessment - Neurological and Sensory Exam: Vital signs are normal. Pt. denies pain on palpation of spine. you feel no deformity. Neurosensory exam is normal. Pt is able to perform range-of-motion without pain or limitation. Motor examination is normal. lRisk / Reliability Assessment: Pt. has no risk factors.

54 Case Study Two (cont) lTreatment: Transport for evaluation of shoulder discomfort. lReassessment: Unchanged. lDiagnosis: No indications for spinal immobilization

55 Case Study Two (cont) lDiscussion: Clinical clearance or inclusion using the algorithm is a systematic approach as noted above. This patient has no indications for spinal immobilization. Be sure to document your exam and treat his shoulder. Transport to the ED is still indicated.

56 Case Study Three lDescription of case: You are called to the home of a 32 year old woman who is complaining of left wrist pain. She is embarrassed that she had to call 911, but she cant stand the pain in her wrist and cant drive herself to the ER. She states that she injured her wrist about 6 hours earlier after she fell out of a moving car. She reports her friends said that she was initially unconscious for several minutes. She admits to drinking a few beers prior to the accident.

57 Case Study Three (cont) lInitial Assessment: ABCs are normal. No manual stabilization initially maintained. Pt. denied any neck/back complaints. lDecide Stability of patient: Stable. lEvaluate MOI: Significant. lSecondary Assessment - Neurological and Sensory Exam: Vital signs are stable. Palpation of cervical spine reveals mild tenderness. Manual cervical spine stabilization is obtained. Neurological exam reveals intact sensation to light touch and pain. proprioception is normal. Patient moves all extremities. You note multiple abrasions over forehead, scalp and left arm and leg. Patient has a Babinski reflex on the left and her DTR were decreased on left.

58 Case Study Three (cont) lRisk / Reliability Assessment: Loss of consciousness, alcohol use, associated injuries. lTreatment: Full spinal immobilization. Splint wrist fracture. lReassessment: Unchanged lDiagnosis: Subluxation of C-4 on C-5 with fracture of pedicle and arch of C-4

59 Case Study Three (cont) lDiscussion: This patient required surgery (cervical diskectomy, decompression and fusion with insertion of iliac crest bone dowel) and immobilization with Gardner-Wells tongs. This patient has risk factors as well as mild tenderness on palpation. She also has a distracting injury. There was a significant MOI with several minute loss of consciousness

60 Case Study Four lDescription of case: 5 year old male fell out of tree approximately 10 feet. Landed on hard ground. Parents report patient was unconscious for a few minutes. Child is now alert, oriented and is very quiet and still.

61 Case Study Four (cont) lInitial Assessment: Airway, breathing and circulation are normal. lDecide Stability of patient: Stable. lEvaluate MOI: Significant. lSecondary Assessment - Neurological and Sensory Exam: Vital signs are normal. Secondary exam reveals shoulder pain and burning in both legs. Patient refuses to participate in exam any further or describe any other sensations. lRisk / Reliability Assessment: Patient is at high risk for spinal cord injury/fracture due to age.

62 Case Study Four (cont) lTreatment: Full immobilization lReassessment: Unchanged. lDiagnosis: Spinal cord injury lDiscussion: This patient suffered a fractured clavicle and a spinal cord injury.


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