Prehospital Clearance of Spinal Injury

[FL_Medic]

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

What's to say that you are risking further injury by not immobilizing though. I still haven't found solid research supporting spinal immobilization. I think it is just assumed that we could cause further injury by manipulating the spine. I understand the theory, but saying that you could cause further injury without any research supporting that statement isn't exactly advocating evidence-based medicine.

I don't mean to jump on ya like a tree frog, but this is part of the discussion.

Ps. you have a fine criteria in the protocol, pretty much exactly the same as NEXUS criteria. Which would be advocating EBM.

Edited June 29, 2009 by FL_Medic

[cosgrojo]

Well this topic has brought back some old memories. I was once certified in the great State of Maine (and happened to grow up in vacation-land, until I was able to escape at the age of 18).

I remember when the c-spine rule out came out. Personally I was excited to have something progressive to do in the field that relied on my own assessment and ability to ferret out patient and scene specific information. At the same time I harbored more than a little bit of consternation over allowing some of my fellow co-workers the same amount of latitude. It seemed like a big deal to me. The service I worked for participated in the training and rolled out the protocol for the providers... but was less than enthusiastic about fully pushing the changes. It is not difficult to imagine that they were concerned with possible litigation and liability. Also the service in question is in a tri-state area with employees that are tri-state certified and work in all three systems. Only Maine had the protocol at the time, and the service was worried about people doing the wrong protocol in the wrong state. New Hampshire has since added it as a standard, and Massachusetts does not have an official c-spine rule out... but the ER docs in the area I work in are fine with it if you are able to support your decision appropriately.

FL-Medic - To your seemingly soul consuming quest to validate or invalidate cervical spine immobilization as a whole... I have not done any research at all on this subject and cannot give you any references at all for any of my statements. However... I have to believe that c-spine must be important/effective/beneficial on some level. I believe in pre-hospital c-spine rule out and am happy that I have the ability to practice it in the field. I work in a region that calls for me to quite frequently transport trauma patients to some of the World's best hospitals... Mass General, Brigham and Women's, Beth-Israel, New England Medical Center, Boston Medical Center... and any time that I have brought them a patient that the community hospital I transported from cleared c-spine and authorized transport without re-immobilizing... they have lost their ever-loving mind. Some of the best trauma teams in the country believe that we should have transported the patient on a board for the hour transport + however long they sat at the original ER. Which should clue you into their feelings about iagenic injuries vs. c-spine precaution.

So is my evidence circumstantial? Sure... is my conclusion Evidence or Fact Based? Depends on your definition. As smart as I like to think I am, and as much as I defend the role of Basics in the EMS community, and rail against ALS elitism, I must admit when I am being trumped. I am intimidated by those Doctor's in Boston... they are smart, they are educated, and they are aggressive. When you drop off a patient that to them meets trauma-team activation status... you are not handing care over to just one Doctor... you are continuing patient care onto a TEAM of Doctor's frothing at the mouth to ask the lowly EMT a bunch of questions that may or may not lead to that EMT's cardiac arrest.

It may sound simplistic, and in no way am I saying that your research is not a noble endeavor (I encourage all aspects and avenues of learning), but if c-spine is effective and important to a team of MD's who have the combined experience and education to make me change the color of my underoo's... then it is good enough for me.

[cosgrojo]

Which should clue you into their feelings about iagenic injuries vs. c-spine precaution.

Rare spelling misshap... iatrogenic... not iagenic.

-10 Called on myself. *I am very disappointed In myself... I hope the city can forgive me.*

[MichMedic]

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.

As an active EMS provider for the last 14 years, I have seen patients that have had spinal column injuries with out complaint of pain and ambulatory on scene,

How ever, I do agree that most of the time I see the patients in the hospital cleared by a physician in the same manner applied in this article.

The patients I have encountered had bone injury to the spine without cord damage; this is only picked up on X-Ray not on a physical exam the majority of the time.

I wouldn’t mind a means of clearing a patient from a backboard in the field that would keep myself and my service protected in litigation through a systematic and approved

Clearance of spinal injury, but until there are clear cut conclusive protocols I’m stuck with back boarding every trauma patient. (Which I hate doing) Given the slow changes that come to EMS

In general, Pre Hospital Care providers are on average held to the highest standards then even the in-hospital providers because if something went wrong it is always blamed on EMS whether it was our

Fault or not, and doctors and nurses come down harder on any minor mistakes by EMS providers then any other providers of care across the boards.

There is the reason for CYA in the field it isn’t pretty but there for a reason.

Michael Maczynski EMT-P (Michigan)

As an active EMS provider for the last 14 years, I have seen patients that have had spinal column injuries with out complaint of pain and ambulatory on scene,

How ever, I do agree that most of the time I see the patients in the hospital cleared by a physician in the same manner applied in this article.

The patients I have encountered had bone injury to the spine without cord damage; this is only picked up on X-Ray not on a physical exam the majority of the time.

I wouldn’t mind a means of clearing a patient from a backboard in the field that would keep myself and my service protected in litigation through a systematic and approved

Clearance of spinal injury, but until there are clear cut conclusive protocols I’m stuck with back boarding every trauma patient. (Which I hate doing) Given the slow changes that come to EMS

In general, Pre Hospital Care providers are on average held to the highest standards then even the in-hospital providers because if something went wrong it is always blamed on EMS whether it was our

Fault or not, and doctors and nurses come down harder on any minor mistakes by EMS providers then any other providers of care across the boards.

There is the reason for CYA in the field it isn’t pretty but there for a reason.

Michael Maczynski EMT-P (Michigan)

[oz_paramedic_chick]

FL-medic...I see what you are saying and I agree. I guess sometimes we fail to look at the evidence base for procedures. I guess people just collar if in doubt because then they can say they did something and took precautions for a neck injury (which would include collar). I think a lot of the time people feel it's a security blanket perhaps and makes them feel better for having done something. Despite this a lack of evidence to support spinal immobilisation does make me wonder if perhaps protocols need to be reviewed. In saying this I believe over in the US when you spinal immobilise you collar, strap to a backboard and use foam head blocks. Is that correct? Over here spinal immobilisation involves lying the pt flat, cervical collar, and placing rolled towels next to the pt's head (mainly to remind them not to move their head). We don't carry head blocks and spinal boards are only used for extrication.

[aussiephil]

FL-medic...I see what you are saying and I agree. I guess sometimes we fail to look at the evidence base for procedures. I guess people just collar if in doubt because then they can say they did something and took precautions for a neck injury (which would include collar). I think a lot of the time people feel it's a security blanket perhaps and makes them feel better for having done something. Despite this a lack of evidence to support spinal immobilisation does make me wonder if perhaps protocols need to be reviewed. In saying this I believe over in the US when you spinal immobilise you collar, strap to a backboard and use foam head blocks. Is that correct? Over here spinal immobilisation involves lying the pt flat, cervical collar, and placing rolled towels next to the pt's head (mainly to remind them not to move their head). We don't carry head blocks and spinal boards are only used for extrication.

Firstly, some people hate it when I quote statistics, but in this case, they are relevant.

I only have NSW stats for 2005, however, they are still relevant. In that year in excess of 66,000 people were treated for suspected spinal injury (the proper term is spinal cord injury & I will explain this shortly). Of those treated with this suspicion, based on mechanism of injury & presentation, less than 40 had a spinal cord injury. However, less than 1000 had a spinal injury.

What is the difference I hear you ask??????? A Spinal Injury is an injury to the spine, but does not have to include the spinal cord. A person can have vertebrae fractures, with no spinal cord damage. Our job is to protect their spine, thus reducing the risk of spinal cord injury.

Now lets also look at some other interesting facts. People think that a cervical collar will provide adequate immobilisation to the cervical spine. This is incorrect. It provides apporximatley 35% immobilisation. Head Blocks help & increase this percentage, the big one is the use of a KED. This will effectivley reduce spinal movment by approximatley 85-90%.

Spine boards are an extrication device & can cause movment because of discomfort of the patient, expecially on extended transports.

If you dont believe me, remove clothing down to what you would have on your patient, get strapped to a board & go for a drive. There are a lot of anatomical spaces that are not filled on a spine board. The use of a KED, also an extrication device, but far more suitable, addresses this & while not comfortable, will assist in minimising movement.

The other consideration, in the protocols I have seen on this, is that each officer has an over riding say in clearance or not. If in any doubt treat as if they are.

Edited July 2, 2009 by aussiephil

[oz_paramedic_chick]

aussiephil....i agree i think the KED/NIEJ is severly underutilised and i think many times it is a case of the paramedic can't be bothered. However on that note up here in qld it is my belief that both the spinal board and the KED/NIEJ are extrication devices only and patients are not to be transported on them. I think making the decision about whether to immobilise or not and choosing how to extricate is a complex one and admittingly i only have a base knowldege at this stage as I complete my trauma subject next semester back at uni. It's a subject i've asked many paramedics about and have received many varied answers.

[aussiephil]

aussiephil....i agree i think the KED/NIEJ is severly underutilised and i think many times it is a case of the paramedic can't be bothered. However on that note up here in qld it is my belief that both the spinal board and the KED/NIEJ are extrication devices only and patients are not to be transported on them. I think making the decision about whether to immobilise or not and choosing how to extricate is a complex one and admittingly i only have a base knowldege at this stage as I complete my trauma subject next semester back at uni. It's a subject i've asked many paramedics about and have received many varied answers.

The name tells you that it is an extrication device, it doesnt matter if it is a KED, RED, NEIJ, however, they are designed to be put on & left on, with releas to the legs for transport. A spine board by design is slippery, hard, & even when a person is properly 'secured' they will still move. The stretchers we use are rated for spinal patients, providing support, while still allowing for the natural cavities that appear to be supported.

They are also very underutilsed, as you stated & it is laziness that causes that, but it is also pressure from managment pushing to reduce scene times, rather than pushing to ensure the job is done properly.

[tniuqs]

KED, RED, NEIJ

Have used most of these devices, some when in the development phases ... my personal opinion is the OSS or Oregon Spinal Splint is superior for a few reasons .. a FIRM head spacer and using maxilla as opposed to mandible (a movable joint) as a point of attachment.

I always wondered with AIRWAY being a priority in care that we try to lock the jaw in place ?

oh I don't have shares in the company btw.

cheers

[nremtp]

As I read this I'm glad I work in the UK. We don't have protocols and we don't work under a physician's licence. We have the freedom and education to selectively immobilize. The only way to 'clear' a c spine is radiologicaly as has already been said. We do however apply canadian rules to decide whether to immobilize. The official stance is, immobilize everyone where the mechanism of injury suggests an insult to the c spine and then remove the immobilization if CCR indicates no injury.

When I worked in Western Australia, we did not carry back boards or KEDs on the ambulances. This was due to research which came out of South Africa which indicated that only 3% of people presenting with neck pain in an MVA would have a c spine injury. The most common cause of neck pain is a rear end shunt and the evidence shows that this mechanism of injury does not cause a c spine insult. In WA, we had to walk all patients with nothing but a soft collar on. I disagreed with this but the medical director (in a quasi american system) decided that was what was to be done and to date I can only remember one case in the whole State where a patient actually had a fractured cervical vertebrae.

In the UK, we have the freedom to decide whether to immobilize and do not work under a doctor's licence; we have our own licence and are accountable for our own actions. I certainly don't immobilize everyone but I am cautious of the mechanism of injury and factors which would rule out the selective immobilization. If for example there is a distracting injury, I always immobilize and if the patient is unable to pass a neuro or comply with my questioning then I always immobilize.

If docs choose to use their x ray eyes then let them get on with it! A recent case I treated involved a jockey who had come off a horse at high speed and had landed directly on his head with the horse then landing on top of him. We (two Paramedics and a Technician) proceeded to immobilize the horse until a doctor (an orthopedic surgeon) ordered us not to immobilize the patient and decided (without any examination) that the patient was fine, we objected but this was met with profanity and we discharged our duty of care to him. 20 minutes later, the patient reported tingling in fingers and a lot of pain in neck. Pt was take immediately to hospital where it was discovered there were 2 fractured vertebrae.

If the rules are applied properly and the clinician is competent in the assessment then there is no need for the patient to be immobilized.