1. EMS Field Cervical Spine Assessment Protocol
VVEMS
Todd Lang, MD
EMS Medical Director 1

2. Why do this? Current practice it totally variable
Clear, reproducible local standard
Easy tool to measure compliance
Formal training in cspine evaluation
Can modify in future to incorporate new data

3. Objectives Discuss Risk & Benefit of C Spine Immobilization
Identify ways to safely lower use of C Spine Immobilization
Review structure and function of the nervous system 3

4. Objectives
Identify situations in which full immobilization is indicated
Identify situations in which full spinal immobilization is not indicated
Review VVEMS spinal assessment protocol
Maintain appropriate level of suspicion for this dangerous but rare condition 4

5. Terminology
We use the words “Spinal Assessment” to indicate that we are evaluating the spine for risk of injury.
We are not “Clearing” it or guaranteeing that there are no injuries. We are using medical evidence to formulate a policy to balance the risks and benefits of immobilization for the bulk of our patients.

6. Who can use this protocol?
Only those EMS providers who have successfully completed the training for the VVEMS Spinal Assessment.
This be the didactic portion
Then, pass the test
Then use it! 6

7. What is “NEXUS?” National Emergency X-radiography Utilization Study
Prospective study with 34,069 patients
Evaluated decision rule to identify patients with cervical injury by clinical exam who did not need radiography 7

8. How do we decide in the ED?
Two main studies
NEXUS
Canadian C-Spine Rule

9. NEXUS
Out of 34,069 patients, the decision rule identified 810 of 818 patients with injury
2% of blunt trauma patients had cervical injury
Two patients classified as “unlikely to have injury” actually had a cervical injury.
One of the two one missed patients required surgery. 9

10. NEXUS Did not include MOI
Did include: altered LOC/intoxication, Midline tenderness, distracting injury, neuro exam,
Up to age 60

11. Canadian C Spine Rule Stable, GCS 15 pts.
A dangerous mechanism is considered to be a fall from an elevation of >=3 feet or 5 stairs; an axial load to the head (e.g., diving); a motor vehicle collision at high speed (>100 km per hour) or with rollover or ejection; a collision involving a motorized recreational vehicle; or a bicycle collision.
A simple rear-end motor vehicle collision excludes being pushed into oncoming traffic, being hit by a bus or a large truck, a rollover, and being hit by a high-speed vehicle.

12. Does C-Spine Immobiliztion Work?
No one really knows.

13. Hauswald Study Compared Malaysian patients to New Mexico patients.
Worse outcomes from New Mexico spinal cord injuries: more likely to have disability
Not definitive, but very provocative
No evidence to the contrary, either, yet

14. Benefits of Immobilization
“Standard of Care”
May prevent injury worsening
Thought to prevent liability
Not so convincing, are they? 14

15. Harms of C-spine Immobilzation
Pain
Anxiety
More radiographs and CT scans
Money
Pressure sores
Harder to manage airway
Change in lung function

16. Why immobilize anyone? Unstable cervical injury is rare.
Any protocol needs to:
emphasize safety (sensitivity) over efficiency (specificity)
balance the small benefit of avoiding spinal immobilization in the many patients without injury against the possibly catastrophic harm associated with failing to immobilize the rare patient with significant spinal injury 16

17. The Skull Made up of bones that form immovable joints
Know the “helmet” bones of the skull:
Frontal, parietal, temporal, and occipital
Important in describing injury location
Mandible =
the lower jaw bone
Maxilla =
the upper jaw bone 17

18. Skull Temporal bone (Basilar) skull fractures often diagnosed by exam
Raccoon eyes
Battle’s sign
The middle meningeal artery runs within the temporal and parietal bones
Fractures associated with epidural bleeding 18

19. Skull Exam
Lumps, dents, wounds: describe by location and size and structures seen
Ears: blood or not, TM normal or not
GCS: don’t say “in & out.” Use a number.
Pupils/CN exam
Jaw function, voice, airway

20. CSF (cerebrospinal fluid) bathes brain and spinal cord
Patient with closed head injury who has a “runny nose” is leaking CSF (basilar skull fracture)
Can also come out of ears 20

21. The Spine Cervical (7) Thoracic (12) Lumbar (5) Sacral 5 (1 fused)
Coccyx 4(1 fused) 21

22. The Vertebrae
The spinal cord rests between the bony processes and body of the vertebrae.
The spine of the vertebra is superficial and can be palpated when performing a physical exam. 22

23. Spinal Cord Part of the central nervous system (CNS)
Nerves leaving each vertebra have a specific function.
Bathed in cerebrospinal fluid (CSF).
Protected by bony vertebrae. 23

24. Cervical nerves “C3,4,5 keeps the diaphragm alive!”
C2 neck rotation and sensation
C3 spontaneous breathing
C4 spontaneous breathing
C5 diaphragm, shrugging shoulders
C6 flexion of elbow
C7 extension of elbow 24

25. Cases Requiring Full Immobilization
Patients meeting any of the following criteria must be fully immobilized.
Higher Risk or unknown mechanism of injury
Altered LOC (GCS<15, or changed)
Presence of other distracting painful injury
Subjective spine pain
Subjective neurological deficit
Objective neurological deficit
Objective midline spine tenderness
Any pain with unassisted neck motion 25

26. MOI with some risk Fall MVA High energy injury
Even minor MOI in right (wrong!) patient

27. Higher Risk MOI Violent impact to the head, neck, torso, or pelvis.
Sudden acceleration, deceleration, or lateral bending forces to the neck or torso.
Falls from greater than 3 feet. Elderly patients (>65) falling out of bed or from standing height.
Ejection or fall from motorized or human powered transportation device.
Axial load (diving).
Unwitnessed loss of consciousness/syncope with head trauma 27

28. Mechanism of Injury
A relatively weak tool, but one which is easy and free.
One which has been used more in the past than in the present and future
No really good data to tell us “what MOI can give you a spinal injury?”
We will use this as a part of our first revision of spinal immobilization protocol

29. Altered Level of Alertness
Clearance of the cervical spine requires that the patient be calm, cooperative, clinically sober, and alert.
Includes patients that are poor historians.
Children and toddlers
Some elderly: are they altered from usual?
Generally, GCS must be 15 to clear spine 29

30. Reliable Physical Exam
Language
GCS/Capacity/reproducibility
Hearing
Ability to sense pain

31. LOC/Intox What about “2 beers?” Chronic drunks? Chronic narcotics?
Other drugs like meth?
Just anxious?
No clear answer from literature
Probably more to lose than to gain in this group by not immobilizing

32. Distracting Injury Of variable use
Some injuries are more distracting than others
Not part of Canadian C-S rule
Is part of NEXUS, but was left up to the attending physician to define it
Part of EMS criteria for now
Less used in ED assessment now

33. Presence of Distracting Injury
Any injury that produces pain that impairs the patient’s ability to appreciate other injuries:
Head injury
Long bone fractures
Large lacerations
Abdominal or pelvic pain
Large burns
Medical conditions: cardiac pain or difficulty breathing
This is an equivocal and poorly defined concept
Will remain a part of our EMS algorithm. 33

34. Subjective Neurological Deficit
Patient complains of numbness, tingling, pins and needles, shooting arm pain, etc.
Patient complains of decreased strength or decreased ability to move limbs
Any patient who describes transient numbness and tingling should be fully immobilized even if symptoms have resolved 34

35. Subjective Spine Pain
Patient complains of cervical or thoracic spine pain.
“Do you have any neck or back pain?”
If yes, immobilize. 35

36. Objective Neurological Deficit
Patient cannot move an extremity
Patient’s extremities are flaccid
(Patient has abnormal motor reflexes)
Generally: grips, push pull, flex/extend feet, intact gross sensory in all 4. 36

37. Objective Spine Tenderness
Patient has tenderness upon palpation of the cervical or thoracic spine.
You must palpate each cervical and thoracic vertebra
Continue down spine
Apply an axial load to top of head 37

38. Practice exam! Demo up front 2 people Same every time you do it
You won’t forget a step that way.
Stop at first positive sign and immobilize.
Don’t do ROM if they have pain, n/t, or other sign!

39. Other Exam Abnormality
Your physical exam reveals:
Swelling
Bruising or redness
Abrasions
Deformity

40. Abnormal Motor or Sensory
This has room for error and was source of error in the studies of C-S
Pain down arm/leg, numb/tingle, even transient sx
Bony Tenderness (midline, on the spine)
Pain with ROM

41. Beware the “Stinger” Transient shooting pain down the arm
Common in football
This is a subjective neuro sign and is grounds for concern and immobilization
You can’t get this without injury to a nerve

42. Pain with Unassisted Neck Motion
If ALL of the previous criteria have been satisfied, the final step is to ask the patient to move their neck without your assistance.
If the patient has any subjective pain, they need to be fully immobilized.
“Look to the left and right. Now touch your chin to your chest. Now look back over your head.” 42

43. Bottom Line:
Can they reliably, reproducibly, and convincingly understand you, cooperate, and pay attention for the exam and have a MOI that should not have broken their neck?
If not, immobilize.

44. Guiding Principles
The VVEMS Spinal Assessment Protocol is designed to allow EMS providers to assess and transport those few blunt trauma patients for whom significant injury is unlikely without full immobilization.
Once one criterion for immobilization is positive, immobilize and transport the patient. 44

45. Guiding Principles
Patients who satisfy all of the criteria in the Protocol and who request EMS transport may be transported without full spinal immobilization.
All Protocol criteria must be carefully evaluated and documented for all patients transported without full spinal immobilization. 45

46. VVEMS C-Spine Assessment Tool
Higher risk MOI?
Yes No
Yes
Altered level of alertness? No
Yes
Distracting injury?
Full Spinal Immobilization No
Yes
Objective or subjective neurological deficit?
Yes No
Neck pain or tenderness?
Yes No
Pain with unassisted neck motion? No
Transport without full spinal immobilization 46

47. Sample Documentation MVC low speed GCS15, clear speech
No numb/tingle/pain down arms, moves all 4
No sig injuries
No spine tenderness
Normal ROM w/o pain
Immob not indicated

48. Maine 2002 C-spine

49. 49

50. Guiding Principles
EMS providers should involve online medical direction for any difficult cases, including patients who meet criteria for spinal immobilization, request EMS transport, and refuse immobilization.
If a patient requests transport with full immobilization, EMS providers should comply with their wishes independent of significant injury risk. 50

51. Guiding Principles
The default management of any blunt trauma patient in the field is full immobilization.
EMS providers must use full c-spine immobilization for cases that are vague.
Let us err on the side of caution because a single bad outcome will cause endless suffering 51

52. Conclusion
Always use full immobilization for patients with an unknown or significant MOI.
Elderly patients are more prone to orthopedic injuries and may not present with obvious signs and symptoms of injury.
Contact online Medical Direction for questions in the field. 52

53. Conclusion
A patient with blunt trauma should be fully immobilized unless ALL criteria of the VVEMS Spinal Assessment Protocol are met. 53

54. Don’t fall asleep at the wheel just because spine injuries are rare
Don’t fall asleep at the wheel just because spine injuries are rare! Assess each patient carefully!

55. Sources
Maine 2002 Spinal Assessment Protocol
Hauswald M, et al. Out-of-hospital spinal immobilization: its effect on neurologic injury
EAST Practice Management Guidelines for Identifying Cervical Spine Injuries Following Trauma
Canadian C-Spine rule
NEXUS paper

56. Questions? 56