Prehospital Clearance of Spinal Injury

[FL_Medic]

The following is the most recent post from the paramedicine blog. I am hoping to spark a discussion and get some more opinions. What do your protocols/medical direction allow?

Prehospital Spinal Clearance

It's no secret that I am a diehard advocate of progressive prehospital medicine. I am also a proponent of evidence-based medicine. Sometimes these two views can be conflicting because of the lack of evidence to back new medicine. I have often changed my views on certain treatments in light of new research. The outstanding presence of bias and valid arguments associated with medicine drives me to keep reading on, even after discovering what may seem like a correct answer. Looking in one place will never be an adequate solution to a complicated topic, at least this is true when it comes to medicine.

Here in my EMS system we practice evidence-based medicine. We also like to consider ourselves a pretty progressive organization. Our medical director gives us a lot of leeway, and holds us to a pretty high standard. You could see five different medics treat the same patient five different ways here in our system, and they will all have valid arguments for each treatment.

When it comes to a traumatic injury, backboards and neck collars are used at the discretion of the lead paramedic. I have seen paramedics that immobilize every patient they encounter that was involved in a car accident or any other blunt force traumatic event. I think this might be what we call CYA (cover your ass) procedures. These medics might have seen a missed spinal injury be improperly treated in their career, and an unfortunate victim of that care acquire a lifelong need for a wheelchair.

I have developed my own systematic approach to these trauma patients. Of coarse manual cervical spine immobilization is applied upon initial contact. If the patient is under the influence of alcohol, he/she gets the full package, board and collar. I have just had too many drunks that haven't felt a stab wound or broken arm, let-alone a possible spine injury. This is also a strong consideration with anyone who has recently taken analgesics or elicit drugs. If they aren't under the influence of drugs or alcohol I give an appropriate physical exam. I consider the mechanism of injury and touch the patient to assess for tenderness. If the patient is pain free, able to move all extremities, and rotate their head without pain or involuntary movement, they get to stay off the board. This isn't evidence-based and I have begun to question my own rational.

Luckily, I haven't had this go wrong. I pride myself in my assessment skills and appreciate the patient's comfort level. A backboard is a very uncomfortable bed cushion for someone who doesn't need it. Quite often, if they didn't have pain to begin with, they will after being on a backboard for only a few minutes. Of coarse, muscle pains from being on a hard board is nothing in comparison to chronic paralysis from being mishandled; I can also appreciate this fact.

Recently I read a statement on Trauma.org that has sparked yet another need for further information gathering[1]:

There is no conclusive evidence in the literature that supports clinical clearance of the spine in the prehospital environment. There is enough variation between prehospital and in-hospital assessments to recommend that prehospital removal of spinal immobilisation be avoided.

This is a pretty blunt statement; no conclusive evidence, not any? What is Trauma.org's definition of conclusive, I wonder. I know there must be something out there that supports the paramedic's ability to adequately assess their patient and make a decision like this. I also wonder if the statement is made only in regards to removal of previously applied spinal immobilization. What kind then, manual immobilization or the whole package? Or is this statement in regards to all blunt trauma patients; should we immobilize them all? Maybe they are referring to only neck and/or back pain patients. The list of questions has quickly become a long one, luckily the authors listed their sources.

The first source listed is from a journal that I personally subscribe to, Prehospital Emergency Care. Unfortunately, this is from 1999 and I don't have the issue. I used Medline to find the article but was only able to come up with the abstract. Here is the abstract from the cited study[2]:

INTRODUCTION: Traditional EMS teaching identifies mechanism of injury as an important predictor of spinal injury. Clinical criteria to select patients for immobilization are being studied in Michigan and have been implemented in Maine. Maine requires automatic immobilization of patients with "a positive mechanism" clearly capable of producing spinal injury. OBJECTIVE: To determine whether mechanism of injury affects the ability of clinical criteria to identify patients with spinal injury. METHODS: In this multicenter prospective cohort study, EMS personnel completed a check-off data sheet for prehospital spine-immobilized patients. Data included mechanism of injury and yes/no determinations of the clinical criteria: altered mental status, neurologic deficit, evidence of intoxication, spinal pain or tenderness, and suspected extremity fracture. Hospital outcome data included confirmation of spinal injury and treatment required. Mechanisms of injury were tabulated and rates of spinal injury for each mechanism were calculated. The patients were divided into three different high-risk and low-risk groups. RESULTS: Data were collected for 6,500 patients. There were 209 (3.2%) patients with spinal injuries identified. There were 1,058 patients with 100 (9.4%) injuries in the first high-risk mechanism group, and 5,423 patients with 109 (2%) injuries in the first low-risk group. Criteria identified 97 of 100 (97%) injuries in the high-risk group and 102 of 109 (94%) in the low-risk group. Two additional data divisions yielded identical results. CONCLUSION: Mechanism of injury does not affect the ability of clinical criteria to predict spinal injury in this population.

So the first thing that stands out to me is the year the study was done. 1999 was 10 years ago. Sure, it isn't that long ago, but think of how much things change in the medical field in a matter of a few years. That doesn't mean that the data isn't valid though. The next thing that stands out is the study itself. It is questioning the relevance of mechanism of injury(MOI)in determining a cervical spine injury, not the ability of a paramedic to adequately clear a cervical spine.

This study gave the paramedics a set list of criteria, it didn't expand off of the paramedic's assessment skill. The study used paramedics in their research, but they were not testing the medics, just the method. So if the criteria were invalid, how does this reflect on the assessment skill of a paramedic?

Unfortunately this abstract leads a lot to the imagination. I'm not sure if the low risk group was intended to be injury free and ended up with 94% of them having injuries (highly unlikely). It seems to me like their low risk criteria appropriately identified 94% of the injuries and the high risk criteria caught 97% of the injuries. That seems to have pretty good specificity to me. I am still looking for the full text for this study (hint hint Rogue Medic).

The conclusion pretty much states that MOI does not effect clinical criteria when predicting spinal cord injury. Does this mean that a possible spinal cord injury is not at all predictable by the MOI. I didn't find conclusive evidence (be it just an abstract) that states paramedics should not be clinically clearing the cervical spine in the field.

That isn't exactly what I am looking for though. Without evidence of benifit, we wouldn't be practicing evidence-based medicine. The next refference that Trauma.org cited was a study from The Journal of Trauma. Once again, all I could find (even in my college's extensive database) was the abstract[3]:

OBJECTIVE: Determine the level of agreement between emergency medical technicians (EMTs) and emergency physicians (EPs) when applying an existing emergency medical services/fire department protocol for out-of-hospital clinical cervical spine injury (CSI) clearance in blunt trauma patients. METHODS: Prospective observational study of consecutive blunt trauma patients transported by emergency medical services/fire department during a 3-month study period. The setting was an urban Level I trauma center. Measurement of interrater agreement (kappa) was determined. RESULTS: Mean age of the 190 patients was 34+/-19 years (range, 6 -98 years). Fifty-nine percent of the patients were male. One hundred forty-six patients (77%) were immobilized by EMTs; 17 of these patients were clinically cleared by EPs. Forty-four patients (23%) were clinically cleared by EMTs and presented without CSI precautions; of these, 61% (27 of 44) were immobilized by EPs and 57% (25 of 44) had cervical spine radiographs obtained. Overall, 141 patients (74%) required radiographic clearance. CSI were detected in five patients (2.6%); all five were immobilized in the out-of-hospital setting. Overall disagreement between EMTs and EPs regarding out-of-hospital CSI clearance occurred in 44 patients (23%) (kappa=0.29; 95% confidence interval, 0.15-0.43; p less than 0.01). CONCLUSION: Significant disagreement in clinical CSI clearance exists between EMTs and EPs. Further research and education is recommended before widespread implementation of this practice.

An even older study, done in 1998, but the data is still relevant (also, keep in mind, the Trauma.org article is from 2002). This study doesn't disprove the ability of paramedics, or EMTs for that matter, to clincally clear a cervical spine. This abstract questions whether EMTs and emergency physicians agree. I hate to point this out, but according to the abstract, the EMTs properly immobilized every patient that came back with a positive cervical spine injury. This doesn't disprove the purpose of the study however. What I get out of this is the need for the emergency physicians to be on board with a prehospital spinal clearanace protocol.

These were the only two references cited by Trauma.org. Neither reference seems to disprove the ability of an EMT to clinically clear the cervical spine. What was the original statement in question though?

There is no conclusive evidence in the literature that supports clinical clearance of the spine in the prehospital environment. There is enough variation between prehospital and in-hospital assessments to recommend that prehospital removal of spinal immobilisation be avoided.

We still don't have the conclusive evidence to support cervical spine clearance. One abstract questioned the relationship between MOI and cervical spine injuries. The other study states that physicians and EMTs disagree, but that isn't necessarily a definitive reason to avoid prehospital clearance of the cervical spine. Just because the studies were both conducted in the prehospital environment doesn't mean that they tested the ability of the prehospital personnel.

Works Cited

[1]Brohi K. 2002. "Clinical Clearance of Cervical Spine Injury" Trauma.org, Link to article

[2]Domeier RM, Evans RW, Swor RA, Hancock JB, Fales W, Krohmer J, Frederiksen SM, and Shork MA. 1999. "The reliability of prehospital clinical evaluation for potential spinal injury is not affected by the mechanism of injury." Prehospital Emergency Care: Official Journal Of The National Association Of EMS Physicians And The National Association Of State EMS Directors 3, no. 4: 332-337. MEDLINE with Full Text, EBSCOhost (accessed May 30, 2009).

[3]Meldon SW, Brant TA, Cydulka RK, Collins TE, and Shade BR. 1998. "Out-of-hospital cervical spine clearance: agreement between emergency medical technicians and emergency physicians." The Journal Of Trauma 45, no. 6: 1058-1061. MEDLINE with Full Text, EBSCOhost (accessed May 30, 2009).

Edited May 31, 2009 by FL_Medic

[FL_Medic]

The following is the most recent post from the paramedicine blog. I am hoping to spark a discussion and get some more opinions. What do your protocols/medical direction allow?

Prehospital Spinal Clearance

It's no secret that I am a diehard advocate of progressive prehospital medicine. I am also a proponent of evidence-based medicine. Sometimes these two views can be conflicting because of the lack of evidence to back new medicine. I have often changed my views on certain treatments in light of new research. The outstanding presence of bias and valid arguments associated with medicine drives me to keep reading on, even after discovering what may seem like a correct answer. Looking in one place will never be an adequate solution to a complicated topic, at least this is true when it comes to medicine.

Here in my EMS system we practice evidence-based medicine. We also like to consider ourselves a pretty progressive organization. Our medical director gives us a lot of leeway, and holds us to a pretty high standard. You could see five different medics treat the same patient five different ways here in our system, and they will all have valid arguments for each treatment.

When it comes to a traumatic injury, backboards and neck collars are used at the discretion of the lead paramedic. I have seen paramedics that immobilize every patient they encounter that was involved in a car accident or any other blunt force traumatic event. I think this might be what we call CYA (cover your ass) procedures. These medics might have seen a missed spinal injury be improperly treated in their career, and an unfortunate victim of that care acquire a lifelong need for a wheelchair.

I have developed my own systematic approach to these trauma patients. Of coarse manual cervical spine immobilization is applied upon initial contact. If the patient is under the influence of alcohol, he/she gets the full package, board and collar. I have just had too many drunks that haven't felt a stab wound or broken arm, let-alone a possible spine injury. This is also a strong consideration with anyone who has recently taken analgesics or elicit drugs. If they aren't under the influence of drugs or alcohol I give an appropriate physical exam. I consider the mechanism of injury and touch the patient to assess for tenderness. If the patient is pain free, able to move all extremities, and rotate their head without pain or involuntary movement, they get to stay off the board. This isn't evidence-based and I have begun to question my own rational.

Luckily, I haven't had this go wrong. I pride myself in my assessment skills and appreciate the patient's comfort level. A backboard is a very uncomfortable bed cushion for someone who doesn't need it. Quite often, if they didn't have pain to begin with, they will after being on a backboard for only a few minutes. Of coarse, muscle pains from being on a hard board is nothing in comparison to chronic paralysis from being mishandled; I can also appreciate this fact.

Recently I read a statement on Trauma.org that has sparked yet another need for further information gathering[1]:

This is a pretty blunt statement; no conclusive evidence, not any? What is Trauma.org's definition of conclusive, I wonder. I know there must be something out there that supports the paramedic's ability to adequately assess their patient and make a decision like this. I also wonder if the statement is made only in regards to removal of previously applied spinal immobilization. What kind then, manual immobilization or the whole package? Or is this statement in regards to all blunt trauma patients; should we immobilize them all? Maybe they are referring to only neck and/or back pain patients. The list of questions has quickly become a long one, luckily the authors listed their sources.

The first source listed is from a journal that I personally subscribe to, Prehospital Emergency Care. Unfortunately, this is from 1999 and I don't have the issue. I used Medline to find the article but was only able to come up with the abstract. Here is the abstract from the cited study[2]:

So the first thing that stands out to me is the year the study was done. 1999 was 10 years ago. Sure, it isn't that long ago, but think of how much things change in the medical field in a matter of a few years. That doesn't mean that the data isn't valid though. The next thing that stands out is the study itself. It is questioning the relevance of mechanism of injury(MOI)in determining a cervical spine injury, not the ability of a paramedic to adequately clear a cervical spine.

This study gave the paramedics a set list of criteria, it didn't expand off of the paramedic's assessment skill. The study used paramedics in their research, but they were not testing the medics, just the method. So if the criteria were invalid, how does this reflect on the assessment skill of a paramedic?

Unfortunately this abstract leads a lot to the imagination. I'm not sure if the low risk group was intended to be injury free and ended up with 94% of them having injuries (highly unlikely). It seems to me like their low risk criteria appropriately identified 94% of the injuries and the high risk criteria caught 97% of the injuries. That seems to have pretty good specificity to me. I am still looking for the full text for this study (hint hint Rogue Medic).

The conclusion pretty much states that MOI does not effect clinical criteria when predicting spinal cord injury. Does this mean that a possible spinal cord injury is not at all predictable by the MOI. I didn't find conclusive evidence (be it just an abstract) that states paramedics should not be clinically clearing the cervical spine in the field.

That isn't exactly what I am looking for though. Without evidence of benifit, we wouldn't be practicing evidence-based medicine. The next refference that Trauma.org cited was a study from The Journal of Trauma. Once again, all I could find (even in my college's extensive database) was the abstract[3]:

An even older study, done in 1998, but the data is still relevant (also, keep in mind, the Trauma.org article is from 2002). This study doesn't disprove the ability of paramedics, or EMTs for that matter, to clincally clear a cervical spine. This abstract questions whether EMTs and emergency physicians agree. I hate to point this out, but according to the abstract, the EMTs properly immobilized every patient that came back with a positive cervical spine injury. This doesn't disprove the purpose of the study however. What I get out of this is the need for the emergency physicians to be on board with a prehospital spinal clearanace protocol.

These were the only two references cited by Trauma.org. Neither reference seems to disprove the ability of an EMT to clinically clear the cervical spine. What was the original statement in question though?

We still don't have the conclusive evidence to support cervical spine clearance. One abstract questioned the relationship between MOI and cervical spine injuries. The other study states that physicians and EMTs disagree, but that isn't necessarily a definitive reason to avoid prehospital clearance of the cervical spine. Just because the studies were both conducted in the prehospital environment doesn't mean that they tested the ability of the prehospital personnel.

Works Cited

[1]Brohi K. 2002. "Clinical Clearance of Cervical Spine Injury" Trauma.org, Link to article

[2]Domeier RM, Evans RW, Swor RA, Hancock JB, Fales W, Krohmer J, Frederiksen SM, and Shork MA. 1999. "The reliability of prehospital clinical evaluation for potential spinal injury is not affected by the mechanism of injury." Prehospital Emergency Care: Official Journal Of The National Association Of EMS Physicians And The National Association Of State EMS Directors 3, no. 4: 332-337. MEDLINE with Full Text, EBSCOhost (accessed May 30, 2009).

[3]Meldon SW, Brant TA, Cydulka RK, Collins TE, and Shade BR. 1998. "Out-of-hospital cervical spine clearance: agreement between emergency medical technicians and emergency physicians." The Journal Of Trauma 45, no. 6: 1058-1061. MEDLINE with Full Text, EBSCOhost (accessed May 30, 2009).

PS, before you all start quoting the NEXUS study, I will tell you that it will be the main focus point of part II on the blog. Don't hurt yourself looking for the evidence, I've got it for ya.

[JPINFV]

No conclusive evidence for selective spinal immbolization? My understanding is that there is no conclusive evidence to support spinal immbolization to begin with.

[FireMedic65]

Unless we get x-ray machines and a radiology degree, I def don't feel safe with it. What if they feel no pain and have movement, but there is a hairline fracture and moving them makes it worse?

[Lone Star]

I will concede that a LSB is an uncomfortable device, as well as K.E.D., and cervical collars.

In the hospital setting, the spine is ultimately 'cleared' by radiological imaging, through the use of x-ray, CT scans or MRI's. There are techniques that the attending physicians have at their disposal, (from their far superior education), that allow them to determine the need for such an exam after palpating the spine.

Until we start carrying portable x-ray machines, CT machines or MRI units on our trucks, we have no real 'tools' at our disposal in the field to be making the decision to remove or omit full spinal immobilization. Currently, the only real 'definitive criteria' that we have to make this decision is MOI, and the patient complaining of neck or back pain.

Obviously, with the unconscious patient, we're not going to be hearing them complain about much of anything; leaving us with only the MOI to determine the need for spinal immobilization.

Even if the patient ISN'T complaining of neck and back pain, that doesn't conclusively rule out cervical spine/spinal injury.

Having been in a couple of pretty good 'fender benders', I can state with absolute certainty that the injuries I suffered in those collisions didn’t hurt nearly as bad at the time they were inflicted. A few hours later however, when the adrenaline finally wore off; you can bet that I felt them then!

Since EMS usually shows up only minutes after the collision, how can we actually trust that the patient is ‘fine’ just because they said so? Could the pain of the spinal injury be masked by the adrenaline release due to the collision in the first place?

Absence of notable deformity of the spine is NOT conclusive evidence that the patient’s spine is ‘injury free’, and since we cannot definitively and conclusively rule out the presence of a spinal injury; we have no business not using full spinal immobilization.

[JPINFV]

Until we start carrying portable x-ray machines, CT machines or MRI units on our trucks, we have no real 'tools' at our disposal in the field to be making the decision to remove or omit full spinal immobilization. Currently, the only real 'definitive criteria' that we have to make this decision is MOI, and the patient complaining of neck or back pain.

What about all the patients who get clinically cleared in the ER without the use of those devices? Under the concept of "We can't clear until we have an x-ray machine," isn't any physician who clears c-spine based on clinical findings, instead of radiology findings, committing malpractice? If not, then why is the presence of imaging technology important for a decision that, by it's very nature, does not need these devices?

[Kiwiology]

If I had to list the things I am most vocal about in prehospital care I suppose the top one would be spinal immobilization. Our clinical procedures leave a lot to be desired when it comes to this (well, our medical director in himself leaves a lot to be desired period).

Immobilising the cervical spine

• Life threatening abnormalities within the primary survey take priority over the cervical spine and immobilisation must never impair maintaining adequate airway, breathing and circulation.

• Place the patient supine in a well-fitted hard collar with the head and neck in an anatomically neutral position (3-4 cm of flat pillow or folded towel behind the head). If the patient is placed on their side then maintain this anatomically neutral position if possible.There is usually no role for the ‘recovery position’ in this group of patients.

• Lateral padding (or head blocks) at the side of the head is not required as a routine for all immobilised patients. Lateral padding should be considered if significant movement is anticipated (e.g. over rough terrain), or the patient is unconscious but has normal airway and breathing, or if there are clinical signs of cervical spine injury. Lateral padding must not be used if it interferes with the ability to look after the airway.

• Spine boards and other rigid flat boards are to be used as sliding or extrication devices only. Patients must not be transported on such boards. Scoop stretchers are preferred as they allow stretcher removal at hospital without having to roll or lift the patient.Devices such as the KED should not be used as a spinal immobilisation device in their own right. The primary function of the KED is to keep alignment of the spine during extrication. Once in place, a KED should remain on until the patient is in hospital, but with the strap tension released to enable the patient to be in a supine position.

I (and another ambulance officer) I know have had more than one argument and head-butting session with the education people about this issue. There really are two schools of thought; the American "strap everybody to a longboard" way and the "don't do it because it's uncomfortable, if the patient is not comfortable they will move which may cause further injury" way of thinking.

I have seen people put a collar on, take it off for whatever reason I don't know, then put it back on! I was told one of our wooden long board was "for show only" (although the Paramedic was joking it lets you see into his mindset I suppose).

Never ever have I seen a patient put on a longboard, we always use the scoop stretcher. I'd be interested to see what creates less movement, somebody strapped down to a longboard or somebody strapped to a scoop.

[FireMedic65]

What about all the patients who get clinically cleared in the ER without the use of those devices? Under the concept of "We can't clear until we have an x-ray machine," isn't any physician who clears c-spine based on clinical findings, instead of radiology findings, committing malpractice? If not, then why is the presence of imaging technology important for a decision that, by it's very nature, does not need these devices?

They are doctors... we are not. I'm sure the doc would get a little upset if you cleared a spine in the field.

[ERDoc]

They are doctors... we are not. I'm sure the doc would get a little upset if you cleared a spine in the field.

Not if you knew how to do it appropriately.

[Dustdevil]

They are doctors... we are not. I'm sure the doc would get a little upset if you cleared a spine in the field.

Progressive physicians who are current in the literature will have no problem with it, if done properly. It is the current standard of care, and has been for a good while.

That said, there a still un-tested variable in spinal clearance, and that is the setting of the examination. While the results may be statistically consistent in the ER, more than half an hour after the incident, will we get the same consistent accuracy with people laying in the mud, the blood, and the beer, seconds after the incident? While I am completely on board with the concept of SSI, we do still have some work to do to insure that it is actually relevant to field practice.

Edited May 31, 2009 by Dustdevil