3 Purpose of EMS Selective Spinal Immobilization Guideline Identify and immobilize 100% of patients at risk for unstable injuriesIdentify and NOT immobilize patients who have NO risk for cervical spine injury…
4 IMPORTANT MessageMechanism 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.3/31/2017
5 Cervical Spine Injuries- The Problem Between 2-4% of Blunt Trauma Patients sustain cervical spine injuryImprovements in EMS systems and ATLS have resulted in increased awareness and practice of cervical immobilizationAP, lateral and open mouth odontoid, swimmer’s if c7, top of t1 not visualized.
6 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 yearPatient exposure to radiation>97% of xrays are negativeCost exceeds $175,000,000 /year
7 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 :1About 80% of males with SCI are aged years.
9 Most Common Causes of Adult SCI 45% - MVC20% - Falls15% - Sports15% - Violence5% - other
10 More than 50% of Spinal cord injuries are single vehicle crashes! Mechanism of InjuryMore than 50% of Spinal cord injuries are single vehicle crashes!
11 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 injuredCauses in Children0-10 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:No neuro deficit,Normal Level of alertnessNo evidence of ETOH/ToxNo posterior midline tendernessNo other distracting painful injuryMD to document prior to imaging
13 NEXUS -Results 818 patients with fracture identified All except 8 were identified by clinical decision ruleSensitivity 99% (95% CI %)Negative predictive value 99.8% (95% CI %)Specificity 12.9%Positive predictive value 2.7%
15 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.
17 Kinematics (Mechanism) Process of evaluating the forces and motion involved when an accident occurs to determine what injuries may have resultedBased on fundamental principles of physics described in Newton’s LawProcess of evaluating the forces and motion involved when an accident occurs to determine what injuries may have resultedBased on fundamental principles of physics described in Newton’s LawAn object at rest will stay at rest unless acted on by an outside force.An object in motion will stay in motion unless acted on by an outside force.Energy cannot be created or destroyed, but it can change form.
18 Kinematics of Blunt Spinal Injury HyperextensionHyperflexionCompressionRotationLateral StressDistractionAxial Loading(diving)Blunt TraumaMotor Vehicle CollisionBicycle FallChildren: Fall > 3 feetAdult: Fall from standing height
19 Mechanism of InjuryPhysical manner and forces involved in producing injuries or potential injuriesValuable tool in determining if the a particular set of circumstances could have caused a spinal injuryMechanisms likely to produce spinal injuries occur in MVAs, falls, violence, and sports (including diving accidents)Physical manner and forces involved in producing injuries or potential injuriesValuable tool in determining if the a particular set of circumstances could have caused a spinal injuryMechanisms likely to produce spinal injuries occur in MVAs, falls, violence, and sports (including diving accidents)
20 Cervical Spine Injuries C-spine very flexibleMost frequently injured area of spineMost injuries at C-5/C-6 levelCervical Spine InjuriesVery flexibleMost frequently injured area of spineMost injuries at C-5/C-6 levelLoss of elbow extension/triceps functionSparing elbow flexion/biceps functionSparing shoulder shrug/trapezius functionMechanisms vary including: flexion, extension, lateral bending, rotation, axial loading, and axial distractionMost injuries unstableSerious secondary injury possible with improper extrication/packagingMost dangerous movement = forward flexion
21 Thoracic Spine Injuries T-spine less flexibleNarrow spinal canalCord injury occurs with minimal displacementCommon mechanismsAny cord damage usually complete at this levelMost T-spine injuries occur at T-9/T-10Thoracic Spine InjuriesT-spine less flexibleNarrow spinal canalCord injury occurs with minimal displacementCommon mechanisms include:severe flexion w/ wedge compression of vertebraaxial loading w/ vertebral fragmentationeither way bony fragments directly damage cordAny cord damage usually complete at this levelMost T-spine injuries occur at T-9/T-10junction of fixed (rib support) and flexible components of T-spineConsider unstable
22 Lumbosacral Spine Injuries LS spine flexible nerve roots in roomy spinal canalMay have bony injury w/o cord or nerve root damageSecondary injury still possibleNeurological injury rare w/ isolated sacral injuries
23 Spinal Column InjuryBony spinal injuries may or may not be associated with spinal cord injuryThese bony injuries include:Compression fractures of the vertebraeComminuted fractures of the vertebraeSubluxation (partial dislocation) of the vertebraeOther injuries may include:Sprains- over-stretching or tearing of ligamentsStrains- over-stretching or tearing of the muscles
25 Identification of Mechanism of Injury Clearly Positive Mechanism spinal immobilization indicatedClearly Negative Mechanism spinal immobilization not indicatedUncertain Mechanism MOI alone inconclusive further assessment required to determine if spinal immobilization necessaryIdentification of Mechanism of InjuryClearly Positive Mechanism- violent impact forces, clearly capable of damaging the bony spinal columnExamples:High velocity vehicle crash, a fall from >20 feet, high velocity GSW near the spineClearly Negative Mechanism- No reasonable possibility that the spine might be injured.Examples: Rock dropped on pt.’s foot, Twisted ankle running over rough terrain, GSW to the elbowUncertain Mechanism- uncertainty regarding the impact and forces involved. The spine may or may not be injured. Mechanism alone can not give us a clear answer.Examples: pt. trips over a lamp cord falling to the floor, a 4th grader loses her balance and falls feet from a teeter-totter, a low speed “fender bender” in the parking lot of the Dinsmore Store
26 Uncertain Mechanism Assessment by Clinical Criteria Pain/Tenderness ExamNeurological ExamMotor FunctionSensory FunctionReliable vs. Unreliable Patient Exams
27 Examples of Positive Mechanism Penetrating trauma to head, chest, abdomen, pelvisAxial loading injuryRollover with signs of impactMultiple system injuriesCompressed roof of vehicleFalls greater than 20 feet
28 Examples of Positive Mechanism Death of occupant in same carStruck by vehicle traveling more than 30 mphSevere vehicle deformity, intrusion of car >12 inchesEjection from vehicle
29 Pain/Tenderness Exam Spine Pain Spine Tenderness Almost all spinal injuries associated with either pain or tendernessPt. may not have both so we need to check for bothPainMay be poorly localizedex. Pain felt deep in the neck = spinal painex. Pain from superficial laceration spinal pain even if laceration on the neckTendernessPalpate firmly over the spinous processTenderness = pain caused by palpationSafe if manually immobilize spine during palpation
30 Neurological Exam Motor Function Sensory Function Reliable vs. Unreliable Patient ExamsNeurological ExamMotor FunctionUpper Extremities- abduction/adduction, finger handLower ExtremitiesMotor Exam SummarySensory FunctionAbnormal SensationPain SensationSensory Exam SummaryReliable vs. Unreliable Patient ExamsThe Reliable PatientThe Unreliable PatientSpine Injury Assessment Summary
31 Motor Function Upper Extremities Lower Extremities Abduction/Adduction Finger/Hand extensionLower ExtremitiesPlantar FlexionGreat Toe DorsiflexionMotor FunctionUpper ExtremitiesAbduction/AdductionTests T-1 nerve rootPt.s spreads fingers while you squeeze them togetherNormal feels like a spring w/ R. and L. sides =Finger/Hand extensionTests C-7 Nerve rootPt. holds hands and fingers straight out and keeps them there while you push downYou support the wrist and press downNormal = resistance to moderate pressure equal on both sides
33 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
34 Sensory FunctionAbnormal Sensation- Numbness, weakness, paraesthesia, or ridiculer painPain Sensation- Test ability to distinguish pain from light touch in both upper and lower extremities
35 Examples of Abnormal Neuro Findings Paresthesia distal to injury, unilateral or bilateralUnilateral weakness, motor or sensory findings in limbsAltered level of consciousness or affectAny abnormality to pan, temperature or position sense.
36 Reliable vs. Unreliable Patient Exams INDICATIONS FOR PATIENT EXAM RELIABILITY*NO **YESAcute Stress Reaction (ASR) CalmAgitated, Combative CooperativeIntoxication/Drug Use Sober/No Drug UseAbnormal Mental Status -- Alert & Oriented(Note: be particularly carefulassessing mental status inhead-injured patients)Distracting Injuries – (painful longbone fractures, significant softtissue injuries, etc.)Communication Problems -- Language Barrier, mental handicap, etc.The Reliable PatientCalm, cooperative, sober, alertThe Unreliable PatientOccult spinal injuries nearly always involve unreliable patientsUnreliability may occur for a variety of reasons, such as:Acute Stress Reaction- two kindsSympathetic ASRFight or Flight/Speeds up body functionsMASKS PAINParasympathetic ASRFainting/slows body functionsBrain InjuryIntoxicationAbnormal Mental StatusDistracting InjuriesCommunications Problems
37 Criteria for High Risk/ Unreliable Patients GCS ≤ 12Pediatric ≤ 12, ≥ Elderly 65Alcohol, drug, any mind altering substance use.Other painful injuries.Down Syndrome.Acute stress reaction or severe anxiety.ShockHistory 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 POSITIVE: “Positive mechanism” is determined following the State of Connecticut Trauma Protocols and Regulations. (Example: Fall of 25 feet)S.I. indicatedQUESTIONABLE: “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 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 indicatedNOTE: 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 MessageLong 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 Mechanism is going to be a crucial decision point in this process 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.3/31/2017
48 Case Study OneDispatch68 y/o female c/o weakness to arms, unable to get out of car. Car parked in shopping mall parking lot.ArrivalPt sitting in drivers seat of car, GCS 15, no distressPt states she drove car over concrete parking divider, “really jerking my head” when she drove over 6 inch divider.
49 Case Study One (cont)Initial assessment: ABC’s normal, c-spine control initiatedStable or unstable?Evaluate MOISecondary AssessmentVS normalNo pain on palpation of spineNo deformity palpableLower extremities= normal motor or sensory examUpper extremities= Good sensation to light touch and sharp touch; but, weak motor function
50 Risk/Reliability: Hx of osteoporosis Treatment: Full immobilization Case Study One (cont)Risk/Reliability: Hx of osteoporosisTreatment: Full immobilizationReassessment: 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 Diagnosis: Central Cord Syndrome Discussion Hyperextension mechanism Case Study One (cont)Diagnosis: Central Cord SyndromeDiscussionHyperextension mechanismSwelling of central cordMost common type of cord injuryLoss of motor and sensory function below level of cord injury with greater loss in arms than legs
52 Case Study TwoDescription 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)Initial Assessment: ABCs are normal. Cervical spine stabilization is manually obtained because of the appearance of the cars.Decide Stability of patient: StableEvaluate MOI: Questionable.Secondary 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.Risk / Reliability Assessment: Pt. has no risk factors.
54 Treatment: Transport for evaluation of shoulder discomfort. Case Study Two (cont)Treatment: Transport for evaluation of shoulder discomfort.Reassessment: Unchanged.Diagnosis: No indications for spinal immobilization
55 Case Study Two (cont)Discussion: 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 ThreeDescription 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 can’t stand the pain in her wrist and can’t 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) Initial Assessment: ABCs are normal. No manual stabilization initially maintained. Pt. denied any neck/back complaints.Decide Stability of patient: Stable.Evaluate MOI: Significant.Secondary 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) Risk / Reliability Assessment: Loss of consciousness, alcohol use, associated injuries.Treatment: Full spinal immobilization. Splint wrist fracture.Reassessment: UnchangedDiagnosis: Subluxation of C-4 on C-5 with fracture of pedicle and arch of C-4
59 Case Study Three (cont) Discussion: 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 FourDescription 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)Initial Assessment: Airway, breathing and circulation are normal.Decide Stability of patient: Stable.Evaluate MOI: Significant.Secondary 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.Risk / Reliability Assessment: Patient is at high risk for spinal cord injury/fracture due to age.
62 Treatment: Full immobilization Reassessment: Unchanged. Case Study Four (cont)Treatment: Full immobilizationReassessment: Unchanged.Diagnosis: Spinal cord injuryDiscussion: This patient suffered a fractured clavicle and a spinal cord injury.