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Selective Spine Immobilization Training Program

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Presentation on theme: "Selective Spine Immobilization Training Program"— Presentation transcript:

1 Selective Spine Immobilization Training Program

2 Reasons for New Guideline

3 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…

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. 3/31/2017

5 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 AP, 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 year Patient exposure to radiation >97% of xrays are negative Cost 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 :1 About 80% of males with SCI are aged years.

8 Based on Science

9 Most Common Causes of Adult SCI
45% - MVC 20% - Falls 15% - Sports 15% - Violence 5% - other

10 More than 50% of Spinal cord injuries are single vehicle crashes!
Mechanism of Injury More 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 injured Causes 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: No neuro deficit, Normal Level of alertness No evidence of ETOH/Tox No posterior midline tenderness No other distracting painful injury MD to document prior to imaging

13 NEXUS -Results 818 patients with fracture identified
All except 8 were identified by clinical decision rule Sensitivity 99% (95% CI %) Negative predictive value 99.8% (95% CI %) Specificity 12.9% Positive predictive value 2.7%

14 8 Patients Not Identified By NEXUS Rules

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.

16 Spinal Injuries

17 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 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 An 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
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

19 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) 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)

20 Cervical Spine Injuries
C-spine very flexible Most frequently injured area of spine Most injuries at C-5/C-6 level Cervical Spine Injuries Very flexible Most frequently injured area of spine Most injuries at C-5/C-6 level Loss of elbow extension/triceps function Sparing elbow flexion/biceps function Sparing shoulder shrug/trapezius function Mechanisms vary including: flexion, extension, lateral bending, rotation, axial loading, and axial distraction Most injuries unstable Serious secondary injury possible with improper extrication/packaging Most dangerous movement = forward flexion

21 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 Thoracic Spine Injuries T-spine less flexible Narrow spinal canal Cord injury occurs with minimal displacement Common mechanisms include: severe flexion w/ wedge compression of vertebra axial loading w/ vertebral fragmentation either way bony fragments directly damage cord Any cord damage usually complete at this level Most T-spine injuries occur at T-9/T-10 junction of fixed (rib support) and flexible components of T-spine Consider unstable

22 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

23 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

24 Spine Evaluation

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 Identification of Mechanism of Injury Clearly Positive Mechanism- violent impact forces, clearly capable of damaging the bony spinal column Examples:High velocity vehicle crash, a fall from >20 feet, high velocity GSW near the spine Clearly 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 elbow Uncertain 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 Exam Neurological Exam Motor Function Sensory Function Reliable vs. Unreliable Patient Exams

27 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

28 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

29 Pain/Tenderness Exam Spine Pain Spine Tenderness
Almost all spinal injuries associated with either pain or tenderness Pt. may not have both so we need to check for both Pain May be poorly localized ex. Pain felt deep in the neck = spinal pain ex. Pain from superficial laceration  spinal pain even if laceration on the neck Tenderness Palpate firmly over the spinous process Tenderness = pain caused by palpation Safe if manually immobilize spine during palpation

30 Neurological Exam Motor Function Sensory Function
Reliable vs. Unreliable Patient Exams Neurological Exam Motor Function Upper Extremities- abduction/adduction, finger hand Lower Extremities Motor Exam Summary Sensory Function Abnormal Sensation Pain Sensation Sensory Exam Summary Reliable vs. Unreliable Patient Exams The Reliable Patient The Unreliable Patient Spine Injury Assessment Summary

31 Motor Function Upper Extremities Lower Extremities Abduction/Adduction
Finger/Hand extension Lower Extremities Plantar Flexion Great Toe Dorsiflexion Motor Function Upper Extremities Abduction/Adduction Tests T-1 nerve root Pt.s spreads fingers while you squeeze them together Normal feels like a spring w/ R. and L. sides = Finger/Hand extension Tests C-7 Nerve root Pt. holds hands and fingers straight out and keeps them there while you push down You support the wrist and press down Normal = resistance to moderate pressure equal on both sides

32

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 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

35 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.

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. The Reliable Patient Calm, cooperative, sober, alert The Unreliable Patient Occult spinal injuries nearly always involve unreliable patients Unreliability may occur for a variety of reasons, such as: Acute Stress Reaction- two kinds Sympathetic ASR Fight or Flight/Speeds up body functions MASKS PAIN Parasympathetic ASR Fainting/slows body functions Brain Injury Intoxication Abnormal Mental Status Distracting Injuries Communications Problems

37 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.

38

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. 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.

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 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.

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 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

47 Case Studies

48 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.

49 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

50 Risk/Reliability: Hx of osteoporosis Treatment: Full immobilization
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

51 Diagnosis: Central Cord Syndrome Discussion Hyperextension mechanism
Case Study One (cont) Diagnosis: Central Cord Syndrome Discussion 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 Description 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: Stable Evaluate 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 Three Description 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: Unchanged Diagnosis: 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 Four Description 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 immobilization Reassessment: Unchanged. Diagnosis: Spinal cord injury Discussion: This patient suffered a fractured clavicle and a spinal cord injury.

63 Questions ?


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