Prehospital Clearance of Spinal Injury

[msenecal]

We have been performing selective spinal immobilzation for years in Maine with no major issues. The only issues that arises is when the providers do not do the full assessment. You do not skip any part of it. When a mistake is made medication or spinal clearance the provider ususally skipped a step. A high perdentage of the patient's immobilized are poorly packaged or poor technique is used moving the patient to the board.

My opinion is that immobilizing all patients is not warranted and has the potential to cause the patient more issues. I also feel that MOI should play some part of the assessment. If I have a vehicle that has cartwheeled through a field the patient has probably bought himself a spinal immobilization trip.

There are several studies out there that support either side.

[HERBIE1]

This study was done in 2008 by the Mayo clinic and published this year:

http://www.pubmedcentral.nih.gov/articlere...i?artid=2672978

This is the conclusion of this study:

This spinal immobilization guideline demonstrates efficacy in identifying those at risk for spinal fractures. The guideline accurately identified all cervical fractures found in this study. The use of an age-extreme criterion may enhance this already effective guideline. Further analysis of compliance failures may add to the guideline's ability to predict fractures.More than 20% (9/42) of patients who had spinal fractures found in this study had indications for immobilization, but it was not performed by ambulance staff. Continual training and regular case review with quality assurance programs should frequently evaluate spinal clearance guidelines. Quality assurance, patient follow-up, and audit systems may improve compliance. It is imperative that ambulance systems monitor and continually review this guideline and train for its application.

This is another study, published in the Journal of Trauma, Injury, Infection, and Critical Care in 2005...

I have the full study, but no longer have online access to the complete article. Sorry, but my scanner is down or I would scan this article for you guys This is a citation for the study and abstract:

BACKGROUND: To evaluate the practices and outcomes associated with a statewide, emergency medical services (EMS) protocol for trauma patient spine assessment and selective patient immobilization. METHODS: An EMS spine assessment protocol was instituted on July 1, 2002 for all EMS providers in the state of Maine. Spine immobilization decisions were prospectively collected with EMS encounter data. Prehospital patient data were linked to a statewide hospital database that included all patients treated for spine fracture during the 12-month period following the spine assessment protocol implementation. Incidence of spine fractures among EMS-assessed trauma patients and the correlation between EMS spine immobilization decisions and the presence of spine fractures-stable and unstable-were the primary investigational outcomes. RESULTS: There were 207,545 EMS encounters during the study period, including 31,885 transports to an emergency department for acute trauma-related illness. For this cohort, there were 12,988 (41%) patients transported with EMS spine immobilization. Linkage of EMS and hospital data revealed 154 acute spine fracture patients; 20 (13.0%) transported without EMS-reported spine immobilization interventions. This nonimmobilized group included 19 stable spine fractures and one unstable thoracic spine injury. The protocol sensitivity for immobilization of any acute spine fracture was 87.0% (95% confidence interval [CI], 81.7-92.3) with a negative predictive value of 99.9% (95% CI, 99.8-100). CONCLUSIONS: The use of this statewide EMS spine assessment protocol resulted in one nonimmobilized, unstable spine fracture patient in approximately 32,000 trauma encounters. Presence of the protocol affected a decision not to immobilize greater than half of all EMS-assessed trauma patients. Burton JH, Dunn MG, Harmon NR, Hermanson TA, and Bradshaw JR The Journal of trauma 61(1):161-7, 2006 Jul - Who cited this? | PubMed ID: 16832265 | Fulltext

This is the final paragraph of the discussion, from the full study:

In summary, the use of prehospital EMS spine assessment protocol affected a decision not to immobilize greater than half of all trauma patients in this predominantly rural state. The presence and accuracy of this EMS protocol did not appear to place trauma patients at substantial risk of adverse neurological outcome as a direct consequence of the selective patient spine immobilization decision.

Thus, it seems the selective use of full C-spine precautions is a safe and valid idea -as long as proper protocols and training are provided.

To me, and to any provider that's been doing this for awhile, I think we know when there is a potential for a serious spinal injury based on MOI, exam, or PMH. I can count exactly ONE patient in 30 years who had a C-spine injury that I did not suspect based on his exam or MOI. It was a 60ish man who tripped and fell, sustaining a small head lac. He was ambulatory, with no other complaints or injuries. He simply wanted a bandaid and to go home. For some reason, I chose to fully immobilize this guy(listen to that inner voice, folks)-much to the amazement of my partner and a nurse bystander- and delivered him to the closest ER (BLS)- which happened to be a Level 1 Trauma center. Later that day, the attending trauma surgeon(who I know very well) pulled me over to an Xray viewing box to see something. Of course, being paranoid, I wondered what we had done wrong. LOL

She showed me a nasty looking dislocation/fx of C2-C3 I think- and said it was from my little old man. After I picked up my jaw from the floor, I asked how he was doing. No deficits, he would probably get a halo and would be fine. She gave us an "atta boy" and asked why we had initially immobilized him, based on his MOI and exam. I said I honestly did not know, but am certainly glad we did.

Bottom line- I think we can all agree that a complaint of neck pain after being rear ended at 5MPH should not mandate a full immobilization, and we are finally seeing data to back that up. Experience, education and training(along with a solid protocol) and applying that to patient care is what this business is all about.

Edited June 1, 2009 by HERBIE1

[Doczilla]

I believe the statement about my own systematic approach wasn't meant for praise. I was introducing how I am now questioning my own method. No where in paramedic school or the training of my agency was the afore mentioned literature mentioned or taught. Until now I hadn't seeked the evidence-based result. Basically I am calling myself negligent for not knowing more.

Which I brought attention to it. It's an important epiphany for prehospital providers reading this forum to understand.

PM inbound.

'zilla

[Lone Star]

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?

You'll notice that in the paragraph prior to the one you've quoted speciffically dealt with the doctors determining the need for radiological imaging after palpating for deformities. In case you missed it, here it is again:

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.

[Tom B.]

If the patient has a normal level of alertness, a normal neuro exam, no signs of intoxication, no pain on palpation of the spine, no painful distracting injuries, and no pain with 45 degree lateral movement, flexion, or extension of the head, then no spinal injury exists. This is well supported in the evidence based literature.

The spine is a bag of bones, and it hurts when it gets fractured. I don't put every patient with a MOI in bilateral traction splints, and I don't put every patient with a MOI on a LSB.

Be a professional. Learn your job. Do it well.

Or, find something else to do.

Tom

[HERBIE1]

If the patient has a normal level of alertness, a normal neuro exam, no signs of intoxication, no pain on palpation of the spine, no painful distracting injuries, and no pain with 45 degree lateral movement, flexion, or extension of the head, then no spinal injury exists. This is well supported in the evidence based literature.

The spine is a bag of bones, and it hurts when it gets fractured. I don't put every patient with a MOI in bilateral traction splints, and I don't put every patient with a MOI on a LSB.

Be a professional. Learn your job. Do it well.

Or, find something else to do.

Tom

Either you work in a progressive system that allows you to make that determination, or you are playing with fire. I'm thinking the former. The skills needed to clinically clear a C-spine aren't difficult to learn, but then again, we work under someone else's license so if we make a mistake, they will need to answer for it as well as the provider.

[ERDoc]

Either you work in a progressive system that allows you to make that determination, or you are playing with fire. I'm thinking the former. The skills needed to clinically clear a C-spine aren't difficult to learn, but then again, we work under someone else's license so if we make a mistake, they will need to answer for it as well as the provider.

You are correct. It is not difficult to learn the criteria. It probably takes about 30 seconds to learn the 5 NEXUS criteria, maybe a little longer to learn the CCR. The difficulty comes in appreciating the limitations of the studies and the clinical decisions rules that were developed.

[Tom B.]

Reasonable people can disagree as to what constitutes a painful distracting injury, but I don't see how this is different than any other skill in the paramedic scope of practice (advanced airway, 12 lead ECG interpretation, etc.) If a paramedic makes a bad decision, then where are the quality feedback mechanisms? Every EMS system has sentinel events, regardless of protocols, regardless of how "progressive". A good EMS system apprehends fallouts as learning opportunities.

We had a paramedic who once failed to backboard a head-injured patient because the neuro exam was "baseline according to the nurse" (the patient suffered from dementia). The Medical Director explained to the paramedic that anything that compromised the physical exam meant that the spine could not be cleared. I assume the paramedic in question won't make the same mistake again.

Isn't that the point? If your idea of risk management and quality patient care is "100% oxygen and a backboard for everyone because it's easier than educating the staff" then I'm not sure it's the best possible approach to ensuring that our citizens are well taken care of.

Tom

You are correct. It is not difficult to learn the criteria. It probably takes about 30 seconds to learn the 5 NEXUS criteria, maybe a little longer to learn the CCR. The difficulty comes in appreciating the limitations of the studies and the clinical decisions rules that were developed.

[ERDoc]

Reasonable people can disagree as to what constitutes a painful distracting injury, but I don't see how this is different than any other skill in the paramedic scope of practice (advanced airway, 12 lead ECG interpretation, etc.) If a paramedic makes a bad decision, then where are the quality feedback mechanisms? Every EMS system has sentinel events, regardless of protocols, regardless of how "progressive". A good EMS system apprehends fallouts as learning opportunities.

We had a paramedic who once failed to backboard a head-injured patient because the neuro exam was "baseline according to the nurse" (the patient suffered from dementia). The Medical Director explained to the paramedic that anything that compromised the physical exam meant that the spine could not be cleared. I assume the paramedic in question won't make the same mistake again.

Isn't that the point? If your idea of risk management and quality patient care is "100% oxygen and a backboard for everyone because it's easier than educating the staff" then I'm not sure it's the best possible approach to ensuring that our citizens are well taken care of.

Tom

I hope I didn't come off as saying that there shouldn't be prehospital protocols. I am in full support of prehospital providers being able to clear c-spines. I think it is great that you work in a system that allows you to use EBM to treat pts.

[Tom B.]

I wouldn't go that far, ERDoc!

I work in a system that sometimes allows me to use EBM to treat patients.

Tom

I hope I didn't come off as saying that there shouldn't be prehospital protocols. I am in full support of prehospital providers being able to clear c-spines. I think it is great that you work in a system that allows you to use EBM to treat pts.