1. Spinal Assessment When to Immobilize and When Not to Immobilize

2. Program Goals All patients who are injured will be properly assessed and treated for spinal injuries in accordance with the Spinal Assessment protocol Describe when & under what circumstances the Spine Protocol can be used Describe the core components of the assessment Differentiate between: – Reliable and unreliable patients – Distracting and non-distracting injury – Normal versus abnormal neurological evaluation – Complaints of spine pain/tenderness from patients without soine pain/tenderness Evaluate injured patients in accordance with spinal assessment protocol and determine if immobilization is warranted Describe the importance proper QA/QI in spinal immobilization

3. History Topic of great attention over past decade Impact on individuals and society Pre-Hospital care of spine injury still debated Consequence of pre-hospital immobilization

4. Clinical Clearance of Patients What the literature says What it lead to

5. NEXUS Study Group What was it? – multi-center investigation enrolled 34,069 patients with 818 identified cervical spine fractures – evaluated a 5-step clinical decision rule for cervical spine assessment 1). Midline posterior cervical spine tenderness 2). Focal neurologic deficit 3). Altered mental status/altered level of alertness 4). Acute intoxication 5). Presence of painful, distracting injury What did NEXUS find? – the decision rule to accurately identify nearly 100% of all significant cervical spine injuries a “missed injury” frequency of approximately 1 in 4000 patients – application of the decision rule to emergency practice would have resulted in approximately 13% fewer radiographic studies at the participating centers How does it apply to EMS? – NEXUS findings can be generalized to apply to the vast majority of pre-hospital populations Exclusions special groups of patients with injury risk factors beyond those discovered in the typical patient population

6. EMS Providers – Extension of the ED EMS providers are a vital part of the delivery of emergency care – Have the tools of assessment, treatment, technology, and participate in the QA/QI process EMS professionals are considered an extension of the care provided in the ED – As an extension should be expected to provide care consistent with the standards practiced by their counterparts in the ED New/Revised Spinal Assessment Protocol – Attempts to align pre-hospital practice with ED practice and consistent with NEXUS – “First, do no harm.” – providers are expected to use the new protocol to the patients’ benefit in choosing who needs pre- hospital immobilization

7. Spinal Assessment

8. What won’t be covered in this section – Scene safety, universal precautions, resource allocation, primary survey, life-threatening injuries, O2 and IV therapy – This should be second nature to all pre-hospital providers What will be covered in this section – Possible high-risk factors and mechanism of injury to consider proceeding to a spinal assessment – The 4 clinical spinal assessment criteria for spinal assessment

9. Mechanism of Injury and High Risk Factors High Risk Factors Mechanism of Injury – Axial load (diving) – blunt trauma – MVC* or bicycle – fall >3ft – adult fall from standing

10. Patient Reliability Is the patient reliable or unreliable? – Is the patient intoxicated, do they have an altered mental status, are they having an acute stress reaction, or some other response that makes the provider question their alertness Unreliable – If the patient is deemed to be unreliable based on the assessment - Immobilize Reliable Proceed to next step in spinal assessment process Clearance of the spine requires the patient to be calm, cooperative, sober, and alert

11. Distracting Injury Does the patient have a distracting injury? – Distracting injury includes any injury that produces clinically apparent pain that might distract the patient from the pain of a spine injury pain would include medical as well as traumatic etiologies of pain. – Distracting injury present the patient should be immobilized – No distracting injury proceed to next step in spinal assessment process What about atraumatic injuries? Non-significant traumatic injuries?

12. Abnormal Sensory/Motor Exam What is the Sensory/Motor Exam? – Commonly accepted assessment means for consideration of motor or sensory deficits from spine injury. What is abnormal? – Paresthesias or loss of sensation in extremities – Weakness or paralysis of extremities – Loss of urethral or sphincter control – Additional findings that would suggest a neurological deficit Exam is abnormal? – Abnormal Sensory response/deficit or abnormal/deficit motor response present the patient should be immobilized – No abnormal sensory or motor deficits proceed to next step in spinal assessment process

13. Spine Pain or Tenderness Examine the spine – Complete an assessment of the patient’s spine for pain and tenderness. – The assessment should include, but is not limited to, palpation of the posterior, midline spine, and cervical spine Spine Pain/Tenderness found? – Assessment finds the patient experiencing any pain or tenderness along the spine the patient should be immobilized – No spine pain/tenderness found do not immobilize the patient. Transport to the most appropriate hospital

14. When Not to Immobilize If it is determined through assessment that the patient is: 1) Reliable 2) Has no distracting Injuries 3) Has no abnormal sensory/motor deficits 4) Has no spine pain/tenderness You do not need to utilize spinal immobilization on the patient. – Transport them in the normal manner as accepted by pre- hospital practice

15. QA/QI Process Quality Assurance form – Services can complete whenever a patient is assessed utilizing the Spinal Assessment Protocol – Submit to local ambulance service QA/QI coordinator/medical director – Submit an electronic copy to the Regional EMS Council for compilation

16. Frequent Questions What if we are unsure about the patient at any point during the assessment of the spine? – Proceed to spinal immobilization – The first rule is “to do no harm”. If the provider is unsure about the patient, the assessment, disagreement between providers, etc. always err on the side of caution Why is mechanism of injury not part of the spinal assessment protocol?

17. Acknowledgements Joanne Lebrun Regional Coordinator Tri-County EMS 300 Main St. Lewiston, ME 04240 Jay Bradshaw Director Maine Emergency Medical Services Department of Public Safety 45 Commerce Drive Suite 1 152 State House Station Augusta, ME 04333-0152 Maine Emergency Medical Services Spine protocol materials State of New Hampshire Advanced Spinal Assessment Protocol

18. Questions??