Prehospital Clearance of Spinal Injury

[Happiness]

Well I apperently hit a nerve somewhere. Its not that I dont want to learn or do things for the profession. First my concern is the patient and that I do no harm to them. Basically what I was saying in my long winded way is that if I feel that if I look at the whole scene and think that there is the SLIGHTEST chance that my pt has a spinal concern Im doing it. If I look like a fool doning it so be it.

When I did my first training session it was a WCB level 3 and they use to teach you how to rule out a spinal. Now they dont teach that because in a community close by a Dr. asked for x-rays (after he took off the collar because the pt didn't have pain or any other sign) the tech says to the guy hop up on my table and we will take the pic. low and behold the pt screamed and collapsed and now lives in a wheel chair because hey he did have a problem. So if Im wrong from learning from others and being to suspect with this sorry but I do error on the side of caution and there is not one thing wrong with that. And FYI I do rule out Spinal procautions but I dont do it because of a study I do it because of the training Iv recieved that actually shows me how to do it and do it right.

[JPINFV]

In addition, since we are discussing EBM, is there any good peer reviewed evidence that says spinal immobilization with a LSB is even effective?

Take care,

chbare.

Effective in which way?

Effective in immobilizing the spine or effective in reducing secondary spinal injury?

[chbare]

Actually, you do, because our education is typically derived from EBM. I did say "typically."

Take care,

chbare.

Effective in which way?

Effective in immobilizing the spine or effective in reducing secondary spinal injury?

Effective in preventing/reducing secondary injury or preventing additional injury from an unstable spinal injury.

Take care,

chbare.

[FL_Medic]

PART 2 From paramedicine blog

A closer look at the research...

With the start of this topic, I thought I would get by with some easy research and criticisms. As I dove into this subject I soon realized it wasn't going to be that easy. In part one, I explained what struck the question and I began to look further into statements made by Trauma.org. The replies to my first post have given me new ideas and directions. The research is all there for me, and there isn't a need to reinvent the wheel here. There is a need however to ask some good questions and get the unbiased answers. In my next couple of posts on this subject I will try to take a look at the timeline of research and with skepticism I will provide you with the evidence I find. With the evidence out there, I don't see a reason we don't have a universally accepted guideline for clinically clearing the cervical spine in the prehospital environment. Liability is unfortunately the most-likely answer to a question like this one--not science.

The 1999 study mentioned in part one listed Michigan and Maine as cohorts that implemented the criteria they studied for the use of spinal immobilization depending on mechanism of injury. After a couple go-arounds with Google, I found the 2005 edition of the Spinal Injury Assessment and Immobilization guideline of the Southeast Michigan Regional Protocol. I was able to find Maine's 2002 protocol, post NEXUS, and found it very interesting. I am going to get into those in a further post to stay chronological.

I want to take a look at some literature I found from the AANS & CNS that was done just after the turn of the new century. This was done prior to the NEXUS study (I will get into this study later) so NEXUS didn't make the 101 reference list. That's right, there is really 101 references, consisting of research from 1966 to 2001.

Right from the get-go[1]:

Standards: There is insufficient evidence to support treatment standards.

Guidelines: There is insufficient evidence to support treatment guidelines.

In the 101 references they listed, they couldn't find enough evidence to support treatment standards or guidelines. Almost 40 years of research, no sufficient evidence--amazing! Give me time and I will go through their references, but for now lets take a further look at what this paper has to say.

Options:

It is suggested that all trauma patients with a cervical spinal column injury or with a mechanism of injury having the potential to cause cervical spinal injury should be immobilized at the scene and during transport using one of several available methods.

A combination of a rigid cervical collar and supportive blocks on a backboard with straps is very effective in limiting motion of the cervical spine and is recommended. The longstanding practice of attempted cervical spinal immobilization using sandbags and tape alone is not recommended.

They have insufficient evidence to support treatment or guidelines, but they promote a treatment that they have guide-lined. I am being critical of the literature so far, but this next statement gives me good reason:

The chief concern during the initial management of patients with potential cervical spinal injuries is that neurologic function may be impaired due to pathologic motion of the injured vertebrae. It is estimated that 3% to 25% of spinal cord injuries occur after the initial traumatic insult, either during transit or early in the course of management.

Okay, I agree that we should be concerned with causing further harm or injury to our patients. Where do they get their estimate from regarding post-incident spinal cord injuries? They list 6 of there citations after that statement. 3% to 25% is a big margin, and to think that a quarter of all spinal cord injuries could be caused by first responders is scary. It may not be impossible, but I feel this is very unlikely. They then state that multiple cases have been reported where mishandling of the cervical spine lead to injury; they list 4 of there references after that one.

In the same paragraph the paper attributes neurological improvement of the spinal cord injured patients over the last 30 years to EMS. This conclusion was made after they state that in the 1970's, 55% of spinal cord injuries presented with complete lesions and in the 1980's, 61% had incomplete lesions. This is pretty interesting as well, and might lead to one of the answers to a seemingly easy question.

Where is the proof that spinal immobilization even works?

-Rogue Medic

It would be extremely difficult to show that without the implementation of full spinal immobilization a patient would suffer further injury. It is enlightening to read that there has been noticeable improvement since the implementation of prehospital spinal precautions. In further parts of this discussion I will revisit this question because it is a good one and deserves more than a one paragraph answer.

Back to the study in question:

Recently, the use of spinal immobilization for all trauma patients, particularly those with a low likelihood of traumatic cervical spinal injury has been questioned. It is unlikely that all patients rescued from the scene of an accident or site of traumatic injury require spinal immobilization.

They follow this up footnoting four of their citations and a statement regarding a triage-based criteria to determine appropriateness of immobilization. This is exactly what we are looking for. I wish they would have elaborated more in this paper though. Here is an abstract from one of the listed references[2]:

OBJECTIVE: To examine the effect of emergency immobilization on neurologic outcome of patients who have blunt traumatic spinal injuries. METHODS: A 5-year retrospective chart review was carried out at 2 university hospitals. All patients with acute blunt traumatic spinal or spinal cord injuries transported directly from the injury site to the hospital were entered. None of the 120 patients seen at the University of Malaya had spinal immobilization during transport, whereas all 334 patients seen at the University of New Mexico did. The 2 hospitals were comparable in physician training and clinical resources. Neurologic injuries were assigned to 2 categories, disabling or not disabling, by 2 physicians acting independently and blinded to the hospital of origin. Data were analyzed using multivariate logistic regression, with hospital location, patient age, gender, anatomic level of injury, and injury mechanism serving as explanatory variables. RESULTS: There was less neurologic disability in the unimmobilized Malaysian patients (OR 2.03; 95% CI 1.03-3.99; p = 0.04). This corresponds to a <2% p =" 0.34).">

I'm not going to lie, the first thing I always read in these abstracts is the conclusion. Read the conclusion to this one. Doesn't that statement contradict a couple points we just mentioned. How this same paper attributes neurological improvement to EMS, and how immobilization is a vital part of the treatment rendered by EMS. Looks like we revisited Rogue Medic's question earlier than expected. Before we do, I want to look at a few more of this paper's references to see what we can find[3].

OBJECTIVE: To determine whether EMS providers can accurately apply the clinical criteria for clearing cervical spines in trauma patients. METHODS: EMS providers completed a data form based on their initial assessments of all adult trauma patients for whom the mechanism of injury indicated immobilization. Data collected included the presence or absence of: neck pain/tenderness; altered mental status; history of loss of consciousness; drug/alcohol use; neurologic deficit; and other painful/distracting injury. After transport to the ED, emergency physicians (EPs) completed an identical data form based on their assessments. Immobilization was considered to be indicated if any one of the six criteria was present. The EPs and EMS providers were blinded to each other's assessments. Agreement between the EP and EMS assessments was analyzed using the kappa statistic. RESULTS: Five-hundred seventy-three patients were included in the study. The EP and EMS assessments matched in 78.7% (n = 451) of the cases. There were 44 (7.7%) patients for whom EP assessment indicated immobilization, but the EMS assessment did not. The kappa for the individual components of the assessments ranged from 0.35 to 0.81, with the kappa for the decision to immobilize being 0.48. The EMS providers' assessments were generally more conservative than the EPs'. CONCLUSION: EMS and EP assessments to rule out cervical spinal injury have moderate to substantial agreement. However, the authors recommend that systems allowing EMS providers to decide whether to immobilize patients should follow those patients closely to ensure appropriate care and to provide immediate feedback to the EMS providers.

Interestingly enough, this study contradicts statements made in a study in my first post on this subject. The research in the other study concluded that emergency physicians and EMTs disagreed on the matter of cervical spine immobilization. This is a moot point by now because it doesn't prove or disprove anything. Whether EMTs and physicians agree or not does not reflect the efficacy of a prehospital spinal clearance protocol. This next abstract is promising[4]:

OBJECTIVE: To determine whether paramedics can safely use a spinal clearance algorithm to reduce unnecessary spinal immobilization (SI) in the out-of-hospital setting. METHODS: Paramedics were instructed in the use of a spinal clearance algorithm that prompted assessment of the trauma patient's 1) level of consciousness, 2) drug and/or alcohol use, 3) loss of consciousness during the event, 4) presence of spinal pain/tenderness, 5) presence of neurologic deficit, 6) concomitant serious injury, or 7) presence of pain with range of motion. The algorithm indicated that if any of the above were present, the patient should receive full SI, and if all of the above were negative, then SI could be withheld. Paramedics completed a tracking form that included the above and followed the patient to the emergency department (ED). Data were then gathered to determine the presence of spinal fracture, neurologic deficit, or a combination of the two. To compare the trends for SI, a retrospective medical incident report (MIR) review was conducted from the previous year. MIRs were selected based on the same criteria as those used for study inclusion. RESULTS: Two hundred eighty-one patients were included in the study, with 65% (n = 183) of them receiving SI. Two hundred ninety-three MIRs were included in the retrospective sample, with SI being provided 95% (n = 288) of the time. Comparison of these samples shows a 33% reduction in utilization of SI (95% confidence interval: 27.2%- 38.8%). CONCLUSION: An out-of-hospital spinal clearance algorithm administered by paramedics can reduce SI by one-third. Any application of a spinal clearance algorithm should be accompanied by rigorous medical supervision.

I'm sorry if this is turning into a post full of abstracts but this one in-particular is the first one I have read that was conducted before the year 2000 and shows positive results using a prehospital spinal clearance algorithm. This evidence was available prior to the statements made in that Trauma.org article, and could have been cited. I am going to stop criticizing Trauma.org for the rest of this discussion because I think I have proved my point. However, we have gone beyond that and into a greater discussion.

So far, what I have...

Prior to 2002 there has been much scrutiny in regards to the prehospital clearance of the cervical spine. There has been bold statements made by prestigious organizations to emphasize this point. There has been plenty of research on the topic, and as always, it is very contradictory. The question on why to immobilize patients in the first place has been touched on, but we haven't completely answered it yet. We also have some evidence that EMTs are capable of agreeing with emergency physicians on this subject--go figure. I have about 200 more references to sift through, and hopefully I can create a pretty elaborate timeline to show you where we have been and where we are. I have yet to share the conclusive evidence on this matter, but it is coming! Hopefully this will be developed into a universally accepted guideline, since it is somewhat accepted already by many prehospital agencies. I am also going to share some of the protocols from these agencies and hopefully some post-implemented research.

I'm going to take a pause with this literature for now and I will be revisiting it in the near future because some of the other subtopics in this discussion are brought up in this paper. In the next part I am going to take a look at the infamous NEXUS study and PHTLS recommendations. To take part in a current discussion on this post please visit EMTcity.com. I list that forum a lot just because it is the one I actually enjoy posting on. Also, please provide your commentary right here if you have any. I use your comments when authoring these posts.

Works cited

[1]American Association of Neurological Surgeons and the Congress of Neurological Surgeons. "Pre-hospital cervical spinal immobilization following trauma. Sept 2001

[2]Hauswald M, Ong G, et al: Out-of-hospital spinal immobilization: Its effect on neurologic

injury (comments). Academic Emerg Med 5:214-219,1998.

[3]Brown LH, Gough JE, et al: Can EMS providers adequately assess trauma patients for

cervical spinal injury? Pre-Hospital Emergency Care 2:33-36,1989.

[4]Muhr MD, Seabrook DL, et al: Paramedic use of a spinal injury clearance algorithm

reduces spinal immobilization in the out-of-hospital setting. Pre-Hospital Emergency Care

3:1-6,1999.

Edited June 4, 2009 by FL_Medic

[JPINFV]

Have you checked out the website put together by one of the Canadian colleges that reviews EBM practices in EMS?

Here's the one for spinal immobilization.

http://emergency.medicine.dal.ca/ehsprotoc...tID=6295.01#378

They've classified immobilization as having C level of evidence, or "There is poor evidence to support procedure or treatment."

[FL_Medic]

Have you checked out the website put together by one of the Canadian colleges that reviews EBM practices in EMS?

Here's the one for spinal immobilization.

http://emergency.medicine.dal.ca/ehsprotoc...tID=6295.01#378

They've classified immobilization as having C level of evidence, or "There is poor evidence to support procedure or treatment."

Same link gave C-spine clearance a B level of evidence.

[rock_shoes]

Just as an add to the discussion I thought I would add a couple of pertinent links

Canadian C-Spine Rule Vs. Nexus Criteria

Canadian C-Spine Rules

Edited June 6, 2009 by rock_shoes

[akroeze]

Just as an add to the discussion I thought I would add a couple of pertinent links

Canadian C-Spine Rule Vs. Nexus Criteria

Canadian C-Spine Rules

Very interesting the study between CCR and NEXUS. The only comment I'll make upon a quick skim of it is that it was put on by the people who created CCR so there is automatically bias.

[FL_Medic]

Prehospital Spinal Clearance Part III

The evidence is here...

You have heard me mention the NEXUS study a few times, and in this post I am going to finally explain exactly what it is and ask if its the solution.

NEXUS stands for National Emergency X-Radiography Utilization Study. This study has been used in a few different aspects of emergency medicine, but has definitely shown its worth in the prehospital environment. [1]

Fear of failure to identify cervical spine injury has led to extremely liberal use of radiography in patients with blunt trauma and remotely possible neck injury. A number of previous retrospective and small prospective studies have tried to address the question of whether any clinical criteria can identify patients, from among this group, at sufficiently low risk that cervical spine radiography is unnecessary. 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 and projected to enroll more than 20 times as many patients with cervical spine injury than any previous study, NEXUS should be able to answer definitively questions about the validity and reliability of clinical criteria used as a preliminary screen for cervical spine injury.

The following image is of a flowchart that utilizes the NEXUS guidelines to determine whether or not to implicate spinal immobilization. It is almost identical to the one found in my Prehospital Trauma Life Support (PHTLS) book.

I know its hard to read, you can use the instructions on the right side of this page for larger viewing.

This criteria has come from the results of the study and has shown to be successfully implemented in the protocols of a few EMS agencies nationwide. The criterion is very similar to the NEXUS criteria for x-ray in the emergency department. Even though the criteria was initially intended to rule out the need for an x-ray for spinal clearance, it is being used to rule out the need for spinal immobilization. The following is the intended use of the NEXUS criteria.

According to the NEXUS Low-Risk Criteria, cervical spine radiography is indicated for trauma patients unless they exhibit ALL of the following criteria:

1. No posterior midline cervical spine tenderness

and

2. No evidence of intoxication

and

3. Normal level of alertness

and

4. No focal neurological deficit

and

5. No painful distracting injuries

Explanations:

These are for purposes of clarity only. There are not precise

definitions for the individual NEXUS Criteria, which are subject

to interpretation by individual physicians.

1. Midline posterior bony cervical spine tenderness is present if the patient complains of 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.

2. Patients should be considered intoxicated if they have either of the following: a) a recent history by the patient or an observer of intoxication or intoxicating ingestion; or b.) evidence of intoxication on physical examination such as 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 drugs (including but not limited to alcohol) that affect level of alertness.

3. An altered level of alertness can include any of the following: a) Glasgow Coma Scale score of 14 or less; b.) disorientation to person, place, time, or events; c) inability to remember 3 objects at 5 minutes; d) delayed or inappropriate response to external stimuli; or, e) other.

4.Any focal neurologic complaint (by history) or finding (on motor or sensory

examination).

5. No precise definition for distracting painful injury is possible. This includes any condition thought by the clinician to be producing pain sufficient to distract the patient from a second (neck) injury. Examples may include, but are not limited to: a) any long bone fracture; b.) a visceral injury requiring surgical consultation; c) a large laceration, degloving injury, or crush injury; d) large burns: or e) any other injury producing 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.

See how this can easily be converted in to a prehospital guideline? Of coarse you can, I already showed it to you.

It only makes sense that the same criteria that physicians use in their assessment to clear a cervical spine be used by EMTs/paramedics. If it can be taught to a doctor, why not us? We have all seen physicians take the cervical collars, that we have applied, off the patients that we bring in. This criteria has been questioned and compared to other studies such as the Canadian method, and I will go over a retrospective comparison of these two methods in my next post on this topic.

Click here for the Michigan protocol that I mentioned in my last post on this topic. Even though they implement some of the same assessments as NEXUS, they do not cite them as a reference. Their protocol includes a rule in method. If any of the specified findings are present, they are to immobilize.

Click here for the 2002 version of Maine's spinal clearance protocol. They appear to have included all of the NEXUS criteria and then some. They claim to have an increased sensitivity of spinal assessment:

An additional Maine EMS 2002 Spine Assessment Protocol departure from the NEXUS investigation is the direction to immobilize patients for a complaint of neck pain as well as any tenderness present in the prehospital spine assessment. This change is purposefully meant to provide an added level of concern for spine injury by increasing the “sensitivity” of the spine assessment protocol. This direction should also serve as a means for decreasing the disagreement potential between providers’ (both in and out of the hospital) assessment of individual patients.

While the NEXUS investigation applies solely to the cervical spine, large scale clinical trials evaluating clinical decision rules for thoracic, lumbar, or sacral spine injuries have yet to be performed. As a consequence, care of the entire spine generally follows cervical spine assessment and treatment principles.

The prehospital assessment of tenderness should include, but not be limited to, the palpation of the posterior midline spine. While NEXUS has emphasized the sole importance of posterior, midline spine tenderness in cervical spine assessment, the Maine EMS 2002 Spine Assessment Protocol includes consideration of any areas of spine tenderness as a means for immobilization. This decision represents another adaptation of the NEXUS rules in an attempt to improve the instrument’s sensitivity for any spine injury as well as decreasing medical provider disagreement potential.

Finally, we have found research that was done on a large enough scale to be considered conclusive evidence to support a prehospital cervical spine clearance protocol. In fact, it is currently being used by many prehospital clinicians already. So why isn't it universally accepted?

As I stated, in the next post on this topic I will go over the comparison between NEXUS and the Canadian method. Maybe we haven't reached the final answer.

[1]Hoffman JR, Wolfson AB, Todd K, Mower WR: Selective cervical spine radiography in blunt trauma: methodology of the National Emergency X-Radiography Utilization Study (NEXUS). Annals of Emergency Medicine 2001.

[oz_paramedic_chick]

Here in QLD we have exclusion criteria. If a pt has no:

1) ALOC

2) Neck Pain

3) Distracting Injury

4) Intoxication (alcohol or drugs)

5) No neurological dysfunction

Then we don't have to collar. In saying that we still take MOI into account and if in doubt we collar....a $30 collar is better than a lifetime in a wheelchair