C-Spine For Penetrating Injuries

[Mateo_1387]

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?

I have been taught this in my medic class I am currently in. I agree with it whole-heartedly. We use the BTLS book, btw.

In the trauma situation we are taught as medics to deliver the patient to the hospital as rapidly as possible. Trauma is something we can try to manage, but not something we can fix. It takes surgeons to fix trauma problems.

When we encounter a patients say with a GSW to the Left side of the chest and he is A/O and no neurological deficits, we can safely assume there is no immediate spinal injury. At this point what is going to help your patient is a trauma surgeon, not a backboard and C-collar and 3-4 extra minutes on scene to package the patient.

Every second used unnecessarily is time the patient is possibly developing one or more of the deadly dozen. In the cases where the patient shows neurological deficit or possibly AMS, ETOH, Significant MOI (the drunk guy who falls from 2 floors up) then spinal immobilization is necessary. He still needs the surgeon, but he also needs the backboard. But there are still times where I would move a patient who meets backboard criteria without immobilizing the patient. For instance if the patient is in a tight spot and he has a pulse but is unconscious due to trauma, and not able to be immobilized, at that point it would be life over limb.

[Capman]

Those are all valid points mateo', but the problem I see, is that remote possibility where a penetrating injury may have compromised the spinal cord. With penetrating injuries, there is that distracting injury (the entry wound). In this case, a patient can not indicate pain in the back/spine due to the distraction of excruciating pain at the entry wound.

I don't know...

I think this one will divide the forum.

The question is... When can we expect to see it back in PHTLS??? Or will it stay out of the books for good???

[stcommodore]

Two cases:

20 YOM, GSW to left shoulder with no exit would, cardiac arrest. Unsafe/Unstable scene, Do you LSB?

35 YOM GSW Chest, No Neuro Deficit, A0x4, CC: Resp Distress corrected via Needle D, Do you LSB?

Both patients I treated during medic school and neither got LSB, in fact in the many GSW cases I saw we never LBS'ed a single one. This was a hospital based system, with the hospital being a trauma center.

[Mateo_1387]

the problem I see, is that remote possibility where a penetrating injury may have compromised the spinal cord.

I don't know...

The question is... When can we expect to see it back in PHTLS??? Or will it stay out of the books for good???

There is a chance of a compromised spinal cord injury due to penetrating trauma. If you do a complete and adequate neurological assessment then you can find a spinal injury or the absence of one. Like I said earlier if the patient is not showing the signs of the injury then he most likely doesn't have one. Statistics prove this. Spinal immobilization has always been a "standard of care" and it is being researched. The findings show that too many people are back boarded unnecessarily.

[Mateo_1387]

Two cases:

20 YOM, GSW to left shoulder with no exit would, cardiac arrest. Unsafe/Unstable scene, Do you LSB?

35 YOM GSW Chest, No Neuro Deficit, A0x4, CC: Resp Distress corrected via Needle D, Do you LSB?

Case 1, Unsafe scene, Cardiac arrest, probably wouldn't work in the first place.

Case 2, No LSB, he needs a truma surgeon, not a long spine board....

[stcommodore]

Case and point, penetrating trauma with no neuro deficit on EMS arrival = no need for LSB

[Capman]

Case and point, penetrating trauma with no neuro deficit on EMS arrival = no need for LSB

Are the absence of neuro deficits grounds alone for a spinal rule out? Think about it, has every spinal injury that you have been on presented with neuro deficits? There have been some I have been to that have not. That is what causes me to worry.

If the mechanism of injury is there, and there is a distracting injury/pain, the potential C-spine injury will always be sitting in the back of my head haunting me if I do a rule out based on the absence of neuro deficits.

What are the additional rule outs in your C-spine protocol? I'm curious to see if all of locations vary on this. Do not refer to PHTLS to answer this, because we know it is the same for all of us.

Thanks

[WANTYNU]

Two cases:

20 YOM, GSW to left shoulder with no exit would, cardiac arrest. Unsafe/Unstable scene, Do you LSB?

35 YOM GSW Chest, No Neuro Deficit, A0x4, CC: Resp Distress corrected via Needle D, Do you LSB?

Both patients I treated during medic school and neither got LSB, in fact in the many GSW cases I saw we never LBS'ed a single one. This was a hospital based system, with the hospital being a trauma center.

Huh?

OK let’s take either case, the traumatic cardiac arrest or the A&OX3 with the needle decompression, please explain how a long board is not part of the standard of care?

Are x-ray machines now on the ambulance? How do you know where the bullet stopped, where is it resting, has it fragmented (with or without an exit wound), spinal immobilization serves more purposes then to protect the spine, it keeps the body stable, takes 1 minute (add a minute if your patient is moving) to get the patient on the board and ready to move, no big deal.

Because a treatment takes longer than a minute does not mean it should be discounted.

Moving the body causes the internal organs to shift, expand and compress, now if you knew your A&Ox3 Pt has a bullet fragment sitting on the aortic arch ready to puncture it, so that if improperly moved you could find your patients condition changing dramatically for the worse, would you still say throw him on the stretcher? Better yet, he’s ambulatory on scene, walk him to the bus?

The point is you don't know, so how can you treat like you do?

I’m not arguing the point of a peripheral puncture wound; however, have you ever seen a bullet fragment travel from a leg wound to the heart?

Bullets are nasty little buggers, they puncture, tear, rip, bruise, bounce and fragment around the inside of the body, and people who have been shot should be moved with care. Bullets can cause just as much and more trauma as a blunt injury, would you even think transporting someone that fell off a moving bicycle without a LB? Of course not (at least I hope so {hint mechanism of injury} so tell me how a bullet is different), that’s why GSW’s go to trauma centers. There are more than enough cases on record where an entry point was peripheral, and the wound was fatal.

As Always IMHO,

Be Safe,

WANTYNU

[AnthonyM83]

Funny how ERDoc mentioned a bullet traveling up the spine. On that call yesterday, the bullet travelled up his leg from what looked only like an ankle graze...until we felt it under his skin below his knee. I don't have the studies (PHTLS book cites them...I didn't get it b/c I was a role-player), but I wonder what percentage DO end up with spinal injury that manifests later...0%? Or 0.5%?

Our protocol (a guideline...well technically) for EMT-B is ONLY based on MOI . . . For paramedics it seems to be what PHTLS says. So, if EMT's aren't supposed to take into account pain, deformity, neuro deficit, then almost anything would require immobilization... http://ladhs.org/ems/Manuals/Medprotocols/...obilization.pdf

[AnthonyM83]

What do you guys say about blunt trauma to lower back? How do you immobilize? Not talking baseball bat stuff...just stuff where no cervical pain/deformity etc etc, except for lower back.