geri-ground level fall

[Doczilla]

What about the idea of spinal immoblization being more detrimental to health for the elderly?

What about it?

'zilla

[mshow00]

That it actually causes more harm to back board geri pts than to do sheet lifts/pt movers/etc in regards to falls > 6hrs with no complaints of injury or pain and hip fxs with "no suspected spinal injury". I don't understand it, thats why I am asking for speculation on their though process.

[DwayneEMTP]

So Doc, are you then saying that anyone over the age of 65 then gets mindlessly (Please take mindlessly to mean regardless of assessment results) spinaled for any trauma, lets say zyphoid or above, regardless of age/mechanism of injury?

Of course I'm not arguing, just trying to be clear....

Some examples...

85ish year y/o F. Trunk blew down hitting her on at the point of her nose and forehead. Both eyes badly swollen, nose very swollen, negative everything other than stated injury...

90is y/o F, leaning on sink while doing dishes. Her soapy hand slips and she strikes her face on the flat, front edge of the sink. Teeth intact, lips and nose swollen, no fall to the floor, negative everything other than stated complaints....

etc...For the sake of discussion let's assume pain scale below 'distracting injury' threshold.

I'm hoping you understand that these cases are not meant as a challenge to your advice, it's simply that after reading your post I though, "Holy crap! I didn't even think about spinal precautions! (after proper assessment to determine negative everything) But, they were only indicated by age! But Age makes assessments unreliable! But I'm supposed to determine immobilization based on logical criteria!......" And then I tried to kill myself....(OD on M&Ms unsuccessful).

See what I mean? Now I'm not sure what to do...

That's it....I'm calling tomorrow to see if there's any room left in the next basic class.....

Dwayne

[WendyT]

NEXUS criteria do not apply to the elderly for exactly this reason. The Canadian C-Spine Rule specifically excludes patients over the age of 65, and NEXUS has not been validated in this population and therefore does not apply. They are at very high risk for fracture despite minimal mechanism of injury, have underlying bone disease such as osteoarthritis, lack much of the supporting musculature that younger patients have, and frequently perceive pain differently from younger patients. Physical exam alone in geriatric patients, for a whole variety of conditions, is notoriously unreliable.

I have had dozens of elderly patients with c-spine fractures from ground level falls. I've found several c-spine fractures on elderly folks that were days or weeks old. Even in unstable fractures from these falls, neurological symptoms have not been present in many.

This is one of those situations where you really do need to immobilize them, regardless of what your gut says. You can take the compassionate approach to c-spine with a c-collar and scoop or a c-collar and securing well to the cot, but you have to treat for this injury.

'zilla

Would you believe last Friday my mother fell out of her wheelchair, and from this fall she fractured her right hip. They tell me she's not a good candidate for surgery. They did a CT and told me her aorta aneurysm is still about the same size-praise god.

They sent her back to the nursing home and the Doctor said bed rest for 1 month, well that's not good either because pneumonia could set in, so we are back to square one.

This fall was due to a faulty seatbelt and it seems that no matter how tiny the problem is, I asked to be notified and wasn't I had to find this out from a PCA.

But hey that's okay I have someone investigating as to what happened to her, where was she when this happened, why the hell was she in her room, when she should of been watching TV. I'm always finding her in the hall or in her room and my Mom is 78 yrs old, this is her first break of any kind.

The orthopedic surgeon told me how my Mother's hip is sitting, it's jammed into her socket-isn't that just lovely.

[Doczilla]

That it actually causes more harm to back board geri pts than to do sheet lifts/pt movers/etc in regards to falls > 6hrs with no complaints of injury or pain and hip fxs with "no suspected spinal injury".

I have not heard this before, nor do I think that it is valid or prudent based on my clinical experience. I agree completely with using patient movers and sheet drags on elderly patients once in the hospital and not leaving them on the backboard, but believe that picking them up off the floor with a sheet is asking for trouble. If this clinical decision rule is based on any study, then I'd like to see it.

I'm not saying that every geriatric patient should be mercilessly strapped to a backboard for the long ride to the hospital, but for these injuries, you must apply a c-collar and take some means to prevent unnecessary movement of the spine. Whether this is with a scoop or a vacuum mattress or just securing them well to the cot with ample padding to prevent lateral movement, you have to address the possibility of spinal injury. In hospital, we put on a c-collar and use manual stabilization when moving the patient from the bed to the CT scanner, etc.

Dwayne- yes, I would immobilize both of the patients you described.

Clinical decision rules such as the NEXUS criteria and CCR assume one thing: that the patient is at relatively low risk for spinal injury. Geriatric patients are not at low risk, for the reasons I listed in my first post. You cannot mindlessly apply a clinical decision rule to every population without fully understanding in what patient population it has been studied and applies. Geriatric patients are different creatures from the 27 year old who suffers the same mechanism of injury.

The CCR specifically excludes patients >age 65 to prevent missing injuries like the one in this patient, and is found to have a higher sensitivity than the NEXUS criteria.

WendyT, I'm not really sure what your post has to do with this topic.

'zilla

[DwayneEMTP]

Got it. So I misunderstood, and rereading your post I shouldn't have, you to mean collar/LBB for all of the patients when you're actually saying collar and best logical appropriate precautions, as opposed to full hardcore precatutions....

Thanks for taking the time to explain Doc. Pretty cool....

Dwayne

[crotchitymedic1986]

Do beat yourself up a little, then learn from your mistake, and go on to be a paragod. Acutually there are several studies regarding the elderly and head trauma from ground level falls, I will see if I can dig some up. Throw a little arthritis and osteoporosis in the mix, and you have the potential for fractures (not to mention that most nursing homes and senior living centers have concrete floors covered with linoleum or tile (their hips break pretty easy from a ground level fall, why wouldnt any other bone). What you may or may not know is that the human brain shrinks as we age, which leaves pockets between the brain and skull. When an elderly person has a brain bleed, the signs and symptoms may not show for hours (because the blood fills the "spaces" and does not compress the brain right away). Until you have a CT or MRI machine on your truck, transport all elderly patients who have fallen.

Edited June 8, 2010 by crotchitymedic1986

[tskstorm]

Do beat yourself up a little, then learn from your mistake, and go on to be a paragod. Acutually there are several studies regarding the elderly and head trauma from ground level falls, I will see if I can dig some up. Throw a little arthritis and osteoporosis in the mix, and you have the potential for fractures (not to mention that most nursing homes and senior living centers have concrete floors covered with linoleum or tile (their hips break pretty easy from a ground level fall, why wouldnt any other bone). What you may or may not know is that the human brain shrinks as we age, which leaves pockets between the brain and skull. When an elderly person has a brain bleed, the signs and symptoms may not show for hours (because the blood fills the "spaces" and does not compress the brain right away). Until you have a CT or MRI machine on your truck, transport all elderly patients who have fallen.

Good thread to dig up. 2 years old.

[rat115]

I'm with Doc that it's important to remember that geriatric pts have a greater risk of fracture with minimal MOI. Some also have increased problems with being back boarded due to curvature of the spine and other pre-existing conditions. That is where using a bit of thought comes in.

Besides a C-collar and spinal board, what does your ambulance have that can be used to make sure there is no neck or back movement?

Here, we've used a spare sheet folded up and wrapped so that it goes behind the pt's neck and is crossed across the chest and secured under the pt arms for both obese pts and for those with spinal curvature that prevented application of a c-collar. This prevented movement with a soft structure which kept the pt comfortable.

In place of a board, we've used a scoop that's been padded with blankets. This fills the gaps naturally and helps the elderly pt feel that they are not going to fall again. It also allows for extra padding to not be in the way when dealing with spinal curvature when you go to move the pt from where they are to the cot and to the ER bed. You can't do this, though, if your service uses metal scoops because they can't be used during x-rays.

Do you have the vacuum splint's that are sheet sized? I've seen those used. They don't work for more than about 3 hrs very well. You MUST also put a sheet under the pt to prevent the pt from sticking to it. (I had a hospital send a pt to another hospital for higher level of care who'd been laying on one for 5 hrs post hip fx. My partner and I were unable to get the pt rolled to get a sheet under her, so we taked to her about what was going on and she opted to be left as she was until we reached the other hospital. The PA who received her had a fit until we explained (and the pt backed) what had happened. The pt ended up having skin peel when we got her off this and the PA had the Ortho surgeon call the first hospital and give an ass chewing.)

[ERDoc]

Just to add to this 2 year old thread. It also depends on where the fx is. If it is just a transverse or spinous process, it's no big deal. Even some fractures of the vertebral ring are stable.