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Spinal Immobilization: Time For a Change?

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Sean Kleckner

on 19 March 2015

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Transcript of Spinal Immobilization: Time For a Change?

Spinal Immobilization: Time For a Change?
by, Sean Kleckner

First.......a little humor.
Spinal Immobilization....Epic Fails
Our Original Article:
"Research Suggest Time for Change in Prehospital Spinal Immobilization"
Majority of EMS textbooks stressed any "significant MOI" = Full Spinal Immobilization
Spinal Immobilization origins lie in the 70's, when most EMS textbooks began advocating back boarding of patients in vehicles with significant damage
No airbags and no damage zones
Precautionary Immobilization
Cont.
1990s (Maine)- Dr. Peter Goth develops spine injury assessment guidelines were shown to be accurate and safe
Originally designed to help ED physicians clinically decide if they can safely clear patients from prehospital spinal immobilization and reduce or eliminate unnecessary radiographic studies.
Shown that "proper clinical exam and history is more accurate at predicting spine injuries than X-ray review"

By Jim Morrissey, 2013
Cont.
Backboard-Based Immobilization Causes...
Increased patient anxiety
Aggravate underlying injuries
Increased risk of aspiration due to inability to protect airway
15-20%
reduction in respiratory capacity
Turning patient = shift in body weight and distribution
C-collar frequently causes increase ICP or abnormal distraction and hides head and neck areas
Development of sacral, heel, or occipital ulcers
VCEMS Policy 614: Spinal Immobilization
National Emergency X-Radiography
Utilization Study (NEXUS) Low-Risk Criteria (NLC)
include five items
The Canadian C-Spine Rule versus the NEXUS
Low-Risk Criteria in Patients with Trauma

Ian G. Stiell, M.D., M.Sc., Catherine M. Clement, R.N., et al.
N Engl J Med 2003;349:2510-8.
Cohort study in 9 Canadian emergency departments comparing the CCR and NLC as applied to alert patients with trauma who were in stable condition.
8283 patients, 169 (2.0 percent) had clinically important cervical-spine injuries
The CCR and NLC were interpreted by 394 physicians for patients before radiography
The CCR would have missed 1 patient and the NLC would have missed 16 patients with important injuries.
CCR was
more sensitive
than the NLC (99.4 percent vs. 90.7 percent) and
more specific
(45.1 percent vs. 36.8 percent, P<0.001) for injury, and its use would have resulted in lower radiography rates (55.9 percent vs. 66.6 percent)
For alert patients with trauma who are in stable condition, the CCR is superior to the NLC with respect to sensitivity and specificity for cervical-spine injury, and its use would result in reduced rates of radiography.

Out-of-Hospital Spinal Immobilization: Its Effect on Neurologic Injury
Mark Hauswald, MD, Graci Ong, MBBS, Dan Tandberg, MD, Zaliha Omar, MBBS 1998
The University Hospital,
University of Malaya in
Kuala Lumpur, Malaysia
University of New Mexico Hospital in Albuquerque, New Mexico
Both locations had comparable levels of trained physicians, similar radiologic, resuscitative, and surgical abilities
Kuala Lumpur location was unique in that their catchment area lacks emergency ambulance coverage
5-year study, that spanned the late 80’s and early 90’s
12,700 trauma patients at the University of New Mexico Hospital
16,000 patients at the University of Malaya Hospital
Out-of-Hospital Spinal Immobilization:
Its Effect on Neurologic Injury
.....Continued
Conclusions
"
98%
probability that immobilization is harmful or of no value.”
“Actual percentage of injuries that are likely to be made worse by lack of immobilization during the immediate post-injury period is much smaller.”
Acute spinal immobilization may not significantly benefit the patient and may not necessarily prevent the further deterioration of an already unstable spinal fracture
Out-of-hospital immobilization has
little or no effect on neurologic outcome
in patients with blunt spinal injuries
Winner!
"It's estimated that at least

patients are immobilized in the prehospital environment in the U.S. each year. Most have

or other evidence of spine injury"
5 MILLION!
NO complaints of neck or back pain
Kwan I, Bunn F. Effects of prehospital spinal immobilization: a systematic review of randomized trials on healthy subjects, Prehosp Disaster Med. 2005;20(1):47-53
McHugh TP, Taylor JP. Unnecessary out-of-hospital use of full spinal immobilization. Acad Emerg Med. 1998;5(3):278-280
Conclusions
Its appropriate for emergency personnel to immobilize certain trauma patients
Its blind-overuse from "precautionary immobilization" can lead to
increased scene time
delay of delivery to definitive care
problematic airway management
increased patient pain or dyspnea
unnecessary patient radiographic testing
so......which one is better?!
In the setting of drowning, the 2010
evidence-based guidelines from the
AHA state that:
Who is getting
on board
?
"Routine c-spine immobilization is a Class III (potentially harmful) unless clear trauma is evident in the history or exam, because it may unnecessarily delay or impede ventilations"
-Berg RA, Hemphill R, Abella BS et al. Part 5: Adult basic life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010;122(18 Suppl 3):S685-S705
The Penetrating Trauma Patient

Unconventional Options
Hartwell Combi-Carrier/Vacuum Mattress Combo
Ferno Germa Easyfix
Challenges Faced With Adoption of New Spinal Immobilization Guidelines
Hard to break long established norms
Extensive training was required to make this new policy successful
Fire Departments, EMS providers, EMS schools, and ED staff needed to be exposed to the literature and trained in the new protocol
Initial outreach and training has been well received and early indicators have shown a significant reduction in spine immobilizations
SKED Stretcher
AlbacMat
"Immobilization has been associated with higher mortality in patients with penetrating trauma"
"Whether penetration occurs in head, neck, or torso, immobilization is unnecessary, interferes with and delays emergent care, and should be seriously reconsidered as the standard of care"
Little or no benefit for gunshot injuries to the torso, even if an unstable spine fracture was present
Airway management, including intubation, is far more complicated and problematic with prehospital spinal immobilization
Failed airway management was reported to be the second leading error preceding death of trauma patients, accounting for of mortality in one study
Morrissey, Jim. Research Suggests Time for
Change in Prehospital Spinal Immobilization.
JEMS. March 2013; 29-39
Morrissey, Jim. Research Suggests Time for
Change in Prehospital Spinal Immobilization.
JEMS. March 2013; 29-39
The Penetrating Trauma Patient
cont......
16%
Many patients can be accurately assessed and treated without immobilization if they meet the criteria in prehospital spinal assessment guides
Extensive initial training and ongoing review is necessary for effective selective immobilization protocol
Unconventional Ideas
One study compared various extrication tools and methods and found that allowing a patient to self extricate from a vehicle with only a Cervical Collar caused less movement of the spine than the use of:
KED extrication device
C-collar and backboard
Cervical Spine Motion During Extrication: A Pilot Study
Jeffery S. Shafer, MD, EMTP and Rosanne S. Naunheim, MD
Western Journal of Emergency Medicine
The University of California, Irvine
Are spinal precautions necessary in all seizure patients?
1,656 cases were reviewed over 10 years.

No spinal injuries were found.
Transportation costs increased approximately 113% and nursing costs increased approximately 57% for patients with seizures placed in spinal precautions.
If spinal precautions were not used in this group, there would be a significant potential cost savings without increased morbidity.
Are Spinal Precautions necessary in all seizure patients?
McArthur CL 3rd. Rooke CT.
Emergency Department, Riverside General Hospital, CA 92503, USA.
Am J Emerg Med. 1995 Sep; 13(5):512-3

LAFD - 2009
Selective Cervical Spine Radiography in Blunt
Trauma: Methodology of the National Emergency
X-Radiography Utilization Study (NEXUS)



Each year in the US, approximately 800,000 people undergo cervical
spine radiography, at a cost of
$180 million
.
• Cervical spine injuries in only 10,000
• The remaining 790,000 individuals (98%)
Unnecessary Expense and Radiation Exposure

1998
The National Emergency X-Radiography Utilization
Study (NEXUS) is a very large, federally supported, multicenter,
prospective study designed to define the sensitivity, for detecting
significant cervical spine injury, of criteria previously shown to
have high negative predictive value.

Done at 23 different emergency departments across the United States

Annual savings nationwide from practice guidelines for radiographs in patients blunt trauma =

Total charges for a limited cervical spine series?.....

$60 Million!
1998
$225
Nexus Criteria Definition
Midline posterior bony cervical-spine tenderness is present if the patient reports
pain on palpation of the posterior midline neck from the nuchal ridge to the
prominence of the first thoracic vertebra, or if the patient evinces pain with
direct palpation of any cervical spinous process.

Patients should be considered intoxicated if they have either of the following:
a recent history provided by the patient or an observer of intoxication or intoxicating
ingestion, or evidence of intoxication on physical examination such as
an odor of alcohol, slurred speech, ataxia, dysmetria, or other cerebellar findings,
or any behavior consistent with intoxication. Patients may also be considered
to be intoxicated if tests of bodily secretions are positive for alcohol or
drugs that affect the level of alertness.

An altered level of alertness can include any of the following: a Glasgow Coma
Scale score of 14 or less; disorientation to person, place, time, or events; an inability
to remember three objects at five minutes; a delayed or inappropriate
response to external stimuli; or other findings.

A focal neurologic deficit is any focal neurologic finding on motor or sensory
examination.

No precise definition of a painful distracting injury is possible. This category
includes any condition thought by the clinician to be producing pain sufficient
to distract the patient from a second (neck) injury. Such injuries may include,
but are not limited to, any long-bone fracture; a visceral injury requiring surgical
consultation; a large laceration, degloving injury, or crush injury; large
burns; or any other injury causing acute functional impairment. Physicians
may also classify any injury as distracting if it is thought to have the potential
to impair the patient’s ability to appreciate other injuries.
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