6Case: 78 yo maleAn 78 yo male brought in Code-3 by EMS after cardiac arrest. Dispatched for “possible heart attack”.Hx: Had been fishing that morning with son with no complaints. Stood up from recliner chair and collapsed onto ground.
7Case: 78 yo male Paramedics found patient apneic, pulseless EKG showed V-fibPatient was successfully defibrillated in field with ROSC.
8Case: 78 yo malePt arrives in ED in NSR, intubated with no spontaneous respiratory effort.He is placed in C-collar in ED because noted to have contusion on forehead.
9Case: 78 yo male CT scan of head is normal CT scan of C-spine revealed type II odontoid fracture with displacementEKG and labs unremarkable
10Case: 78 yo maleFamily elects to have patient extubated, and he expires in EDWould pre-hospital immobilization have effected outcome?Medico-legal liability?
11Case: 49 yo male Motorcycle vs Deer Speed estimated at 45 mph. Patient can’t remember exactly what caused accident, but EMT’s find dead deer nearby.Was wearing full leathers/helmetHe was not intoxicated
12Case: 49 yo male Only c/o L. Shoulder pain Patient arrives not in spinal immobilizationPlaced in c-collar in EDL. Scapula fracture, 2 rib fractures and small L. PTX identified
13Case: 49 yo male CT head and C-spine obtained CT head is normal C-5 transverse process fracture identified
14Case: 49 yo male Fracture is stable and doesn’t effect his outcome He is transferred to a trauma centerUneventful recoveryOut windsurfing a few weeks ago
15Goal Clearing C-spine in the field? Provide clear, simple and safe guidelines for prehospital spinal immobilization.
17Why immobilize? 253,000 people in US living with spinal cord injuries 12,000 new cases each yearIn US, cost of MVC related SCI estimated $34.8 billion per year5 million patients in the US receive spinal immobilization each yearSpinal Cord Injury Information Network (www.spinalcord.uab.edu)
18Epidemiology 77.8% males Average age of injury is increasing: 28.7 yo in 1970’s39.5 yo in 2005Spinal Cord Injury Information Network (www.spinalcord.uab.edu)
20Why immobilize? Why immobilize? AANS 2001 Guidelines for Pre-Hospital Cervical Spinal Immobilization following trauma:“There is insufficient evidence to support treatment standards”“There is insufficient evidence to support treatment guidelines.”American Association of Neurological Surgeons, 2001
21Why immobilize? Why immobilize? “It is estimated that 3 to 25% of spinal cord injuries occur after the initial traumatic insult”:During extricationDuring transitAmerican Association of Neurological Surgeons, 2001
22Why immobilize? Why immobilize? Over the last 30 years there has been a dramatic improvement in the neurologic status of spinal cord injured patients arriving in the emergency department.1970’s - 55% complete neurologic lesions1980’s - 49%American Association of Neurological Surgeons, 2001
23Why immobilize? Why immobilize? What about NHTSA? “This has been attributed to the development of Emergency Medical Services initiated in 1971, and the pre- hospital care (including spinal immobilization) rendered by EMS personnel.What about NHTSA?American Association of Neurological Surgeons, 2001
241999 NAEMSP Position PaperINDICATIONS FOR PREHOSPITAL SPINAL IMMOBILIZATIONRobert M. Domeier, MD, for the National Association of EMS Physicians Standards and Clinical Practice Committee
251999 NAEMSP Position Paper“There have been no reported cases of spinal cord injury developing during appropriate normal patient handling of trauma patients who did not have a cord injury incurred at the time of the trauma.”
261999 NAEMSP Position Paper“Although early emergency medical literature identified mis-handling of patients as a common cause of iatrogenic injury, these instances have not been identified anywhere in the peer-reviewed literature and probably represent anecdote rather than science.”
271999 NAEMSP Position PaperSpine immobilization is indicated with a significant mechanism of injury and at least one of following criteria:Altered mental statusEvidence of intoxicationA distracting painful injury (e.g. Long-bone extremity fracture)Neurologic deficitSpinal pain or tenderness
281999 NAEMSP Position Paper Caveats: Language or communication barriers Extremes of ageDifficult to assess intoxication in fieldVariable interpretation of spinal pain or tenderness
31Kwan, et al 2004 Effects of Prehospital Spinal Immobilization: A Systematic Review of Randomized Trialson Healthy SubjectsIrene Kwan, MSc;1 Frances Bunn, MSc2
32Kwan, et al 2004 2004 Cochrane Review Systematic review of 17/4453 randomized controlled trials comparing types of spinal immobilization devices
33Kwan, et al 2004 Adverse effects of spinal immobilization included: Significant increase in respiratory effortSkin ischemiaPain/discomfort
34ATLS 2008Several studies have shown correlation between the length of time on a rigid spine board and the development of pressure ulcers.“A paralyzed patient who is allowed to lie on a hard board for more than 2 hours is at high risk for serious decubitus ulcers.”2008 ATLS Course Manual, 8th edition
35Increased ICPCervical collars have been associated with elevations of intracranial pressure (ICP)Prospective study of 20 patientsRigid Philadelphia collarSignificant (p = .001) increase in ICP from to mm H20Kolb, et al, Ann Emerg Med. 1999; 17:
36NEXUS National Emergency X-Radiography Utilization Study Prospective, multi-hospitalCervical spine clearance if noIntoxicationDistracting injuryNeuro deficitMidline spine tenderness34,069 at risk for cervical fracture from blunt818 (2.4%) cervical spine injuriesMissed 8 (99% sensitive, 12% specific)Good confidence intervals ( %)Only 2 injuries deemed clinically significantHoffman, et al, NEJM, July 13, 2000, Vol. 343, No. 2; p
37Pediatric Cervical Spines 3065 (9%) of NEXUS patients were <18 years0.98% cervical spine injuryNo SCIWORADecision rule 100% sensitiveConfidence intervals %Viccellio, et al, Pediatrics, Aug 2001, Vol. 108, No. 2
38Vaillancourt, et al 2009The Out-of-Hospital Validation of the Canadian C-Spine Rule by ParamedicsAnn Emerg Med. 2009;54:
39Vaillancourt, et al 2009 Prospective cohort study Alert and stable trauma patientsAdvanced and basic care paramedics interpreted ruleAll were then immobilized and evaluated in EDAnn Emerg Med. 2009;54:
46ATLS 2008“Cervical spine injury requires continuous immobilization of the entire patient with a semirigid cervical collar, head immobilization, backboard, tape, and straps before and during transfer to a definitive-care facility.”2008 ATLS Course Manual, 8th edition
47Kwan, et al 2004The following methods were efficacious in restricting movement:CollarsSpine boardsVacuum splintsAbdominal/torso strapping
48Neutral Postion The “neutral position” is poorly defined: “The anatomic position of the head and torso that one assumes when standing and looking ahead”12° of cervical spine extension on lateral radiographAmerican Association of Neurological Surgeons, 2001
49Neutral Postion“McSwain et al determined that more than 80% of adults require 1.3 cm to 5.1 cm of padding to achieve neutral positioning.”This appears to be a reference to PHTLS textAmerican Association of Neurological Surgeons, 2001
511999 NAEMSP Position Paper“Currently, spinal immobilization is often performed based only on the mechanism of injury without consideration of the patient’s symptoms and physical findings.”
521999 NAEMSP Position Paper“EMS systems adopting procedures for clearance from prehospital spinal immobilization must develop mechanisms for education and quality improvement to ensure safe and appropriate use of clearance protocols.”
53Goal Clearing C-spine in the field? Provide clear, simple and safe guidelines for prehospital spinal immobilization.
54Quality AssuranceProtocol should be:ClearSimpleSafe
55Quality AssuranceSystem should ensure:EfficacyCompliance
56Myers et al, 2009 Retrospective study 2 gold standards: Radiographic findingsPhysician clearance without x-rayMyers, et al, Int J Emerg Med 2009; 2:13-17
57Myers et al, 2009Guideline allows exclusion of spinal immobilization if:No pain, stiffness, soreness or tenderness in the neck or backNo alteration in LOCNo intoxicationNo other painful or distracting conditionNo signs or symptoms of shockMyers, et al, Int J Emerg Med 2009; 2:13-17
58Myers et al, 2009 Included 942 patients 384 did not meet criteria for clearance36 (9.4%) had fractures558 patients met criteria for clearance7 (1.3%) had fracturesMyers, et al, Int J Emerg Med 2009; 2:13-17
59Myers et al, 2009 When immobilization was indicated Caregivers were 77.6% compliantMyers, et al, Int J Emerg Med 2009; 2:13-17
61Myers et al, 2009The median age of the fractures that were immobilized was 48 yearsThe median age of the 7 fractures not immobilized was 82 yearsAn age extreme criteria may enhance this guidelineMyers, et al, Int J Emerg Med 2009; 2:13-17
63Columbia Gorge Protocol SPINAL STABILIZATIONTrauma patients with the following injuries or signs/symptoms should be treated with full spinal immobilization.Head or facial injuryDecreased level of consciousnessHead, neck or back pain, consider spinal stabilization.Any patient meeting the trauma system criteriaThe level of treatment given other patients will be left to the discretion of the senior EMT. The mechanism of injury should be considered in this decision. This protocol is not intended to discourage the use of full spinal immobilization on any patient.Consider padding the upper half of the board for patient comfort if time and circumstances permit.
64Multnomah County Protocol Selective Spinal ImmobilizationImmobilize using a long spine board if the patient has a mecha nism with the potential for causing spinal injury and meets ANY of the following clinical cri teria: A. Altered mental status.B. Evidence of intoxication.C. Distracting pain/injury (extremity fracture, drowning, etc.).D. Neurologic deficit (numbness, tingling or paralysis)E. Spinal pain or tenderness.F. Distracting situation (communication barrier, emotional distr ess, etc.).
65State of Jefferson Protocol SPINAL IMMOBILIZATIONFirst Responder, EMT-B, EMT-I, EMT-PINDICATIONS:Patients with a risk of cervical, thoracic, or lumbar spine injury based on mechanism of injury and findings of spinal pain, tenderness or neurologic abnormality.PROCEDURE:For actual or suspected penetrating trauma of the spine, then spinal immobilization indicatedFor blunt trauma with mechanism for spinal cord injury, then spinal immobilization if any of the following are answered “yes”:
66Jackson County Protocol CriteriaYesNoAge < 10 years or > 65 yearsAltered mental status or loss of consciousnessSignificant mechanism of injury, such as high speed motor vehicle crash axial loading rollover motor vehicle crash fall from greater than standing heightEvidence of intoxicationDistracting injury, such as significant fracture or lacerationNeurological deficitMidline spine pain (subjective)Midline spine tenderness (objective)EMT suspects spinal cord injury based on mechanism, history or exam findings.Pain with active neck rotation or active ROM of neck rotation limited to < 45ºIf any answer is “yes”, then spinal immobilization indicated.
67Case: 78 yo male Age < 10 years or > 65 years Altered mental status or loss of consciousnessEvidence of intoxicationSignificant mechanism of injury, such as high speed motor vehicle crash, axial loading, rollover motor vehicle crash, fall from greater than standing heightDistracting injury, such as significant fracture or lacerationNeurologic deficitMidline spine painMidline spine tendernessEMT suspects spinal cord injury based on mechanism, history or exam findingsPain with active neck rotation or active ROM of neck rotation < 45°
68Case: 49 yo male Age < 10 years or > 65 years Altered mental status or loss of consciousnessEvidence of intoxicationSignificant mechanism of injury, such as high speed motor vehicle crash, axial loading, rollover motor vehicle crash, fall from greater than standing heightDistracting injury, such as significant fracture or lacerationNeurologic deficitMidline spine painMidline spine tendernessEMT suspects spinal cord injury based on mechanism, history or exam findingsPain with active neck rotation or active ROM of neck rotation < 45°
69Jackson County Protocol CriteriaYesNoAge < 10 years or > 65 yearsAltered mental status or loss of consciousnessSignificant mechanism of injury, such as high speed motor vehicle crash axial loading rollover motor vehicle crash fall from greater than standing heightEvidence of intoxicationDistracting injury, such as significant fracture or lacerationNeurological deficitMidline spine pain (subjective)Midline spine tenderness (objective)EMT suspects spinal cord injury based on mechanism, history or exam findings.Pain with active neck rotation or active ROM of neck rotation limited to < 45ºIf any answer is “yes”, then spinal immobilization indicated.