C-Spine For Penetrating Injuries

[AnthonyM83]

I'm helping as a role-player (and getting to sit in) for PHTLS, again. Apparently, PHTLS is saying that spinal immobilization is no longer indicated for penetrating injuries (including GSW's) to the thorax if patient is A&O without pain or neurological deficits (they had this whole little flow-chart).

It seems really counter-intuitive considering concern about cavitation injuries from bullets, but apparently if patient has not had a neuro deficit by the time EMS arrives, then there isn't one (NOT to be confused with faulty thinking that patients with cspine indications can be walked to backboard if already ambulatory).

Has anyone else been taught this? What do you think?

[courageheartx]

A gunshot wound is a form of high velocity trauma. Irregardless of if their neurological response has a deficit,or if they are remarkable on your assesments,I would still suspect a spine injury. When that bullet enters,or any object for that matter enters the body,we as EMS providers don't or can't really detect for a true spinal injury (we suspect). Unless possibly you have xray machine in the back of your unit? I don't know where PHTLS came up with this,but i'd seriously like to find out. A patient who was shot would be collared,and put on a board just like a patient who was just involved in a collision and is walking around upon the arrival EMS..... If you suspect,especially from the mechanism,take every precaution. 1.You would be covering your ass 2.If the patient does have injuries,then you might have possibly prevented something from further occuring. Maybe as my clinical experience is broadened,I might change my views, but for now anyone who has suffered something involving a high mechanism injury or velocity for that matter,will be immobilized and put on a board.

[Capman]

I'm up for PHTLS in about 3 months, and this is interesting. They have always preached C-spine precautions for penetrating injuries. I'm not really sure about the rationale behind doing away with that. I would welcome any information on this as well. We know that they always change something everytime we take CPR, PHTLS, ACLS, Etc., but this one is a big change that could have serious consequences.

Info' welcome.

[AnthonyM83]

Yeah, seems strange to me. And it didn't sit well with a few people in class, though that's often the case when something new comes in where the studies are opposite of what one would think. Does anyone here teach PHTLS? I'm sitting in, so I didn't buy the book, so not sure what the details are or if it lists sources in the back.

[Dustdevil]

I'm up for PHTLS in about 3 months, and this is interesting. They have always preached C-spine precautions for penetrating injuries.

It hasn't always been there. It wasn't there when it started in the mid 80's.

I'm not sure when it came about, but I've never been a particular fan of it.

SSI is the future. PHTLS is just finally getting on board.

[AnthonyM83]

edited. temporary post only.

[Capman]

Yeah, I guess that I can't use the word "always" dust'. PHTLS only dates back 8 years for myself. I'm not really sure what the standards were prior to that.

[ERDoc]

If you think about it, it makes sense. Why do we immobolize in blunt trauma? One reason is for neuro deficit which is a sign of cord injury. Another reason, in the absence of neuro deficit is for a potential unstable injury to the vertebral column that, if allowed to move would result in injury to the cord. In a penetrating injury why are we going to immobilize? If we have neuro deficit, that again is a sure sign of a cord injury. This can be caused by a knife or bullet which violates the vertebral column and directly injures the cord. A penetrating injury is not going to disrupt the vertebral column without causing damage to the cord inside, so if you have no neuro deficit there is no injury to the cord. EVERY penetrating injury that I have seen that has disrupted the spinal column has affected the cord and produced a neuro deficit. Also, if it is a thoracic injury, how is it going to affect the cervical cord? If you are not at risk for a cervical cord injury, why would you need to immobilize?

[AnthonyM83]

The question then arises, why do we cspine for blunt trauma without neuro deficit? In case spine is unstable and certain movements might injury the cord, right? But wouldn't the energy from a bullet with cavitation be similar to blunt trauma and the bullet fragmentation potentially lodge near cord where movement might cause fragments to shift causing injury? That's where it doesn't quite make sense to me...

[Dustdevil]

The question then arises, why do we cspine for blunt trauma without neuro deficit?

Blunt trauma is a pretty broad term. Can you give an example of what kind of blunt trauma you are talking about? There aren't many thoracic blunt traumas I would board for.

But wouldn't the energy from a bullet with cavitation be similar to blunt trauma and the bullet fragmentation potentially lodge near cord where movement might cause fragments to shift causing injury?

I considered myself pretty well read on cavitation at one time, but perhaps I am behind the times now. What exactly would thoracic cavitation have to do with spinal compromise?