C-spine immobilization criteria

[EMS49393]

I ran a call last night in which a bicyclist and a car collided at an intersection at a low rate of speed. By low, I mean the car had traveled three feet from a dead stop before coming in contact with the bicyclist. The speed would have likely been well below 5 mph. The patient was alert, oriented, and had a complaint of "a tired feeling" in his lower thoracic spine area. He had some minor redness to this area that resembled his mesh undershirt. He was ambulatory at the scene and initially wanted to refuse treatment and transport. He had no distracting injuries, no c-spine tenderness, no neurological deficits, no loss of consciousness, and was wearing a helmet as well as a few layers of protective clothing. He states he more or less tipped onto the hood of the car landing on his back. He was NOT thrown into the air, and had contact with the car that probably had less impact than if he would have fallen to the ground from a standing position. No damage to the car or the bike. His vital signs remained well within his normal limits throughout transport. We did not immobilize the patient. My third rider felt the patient didn't require spinal precautions and I agreed based on all the information I gathered. When we got to the ER and gave report to one of the residents, he ordered spinal precautions on the patient. The nurse also decided to give my third rider a hard time over not taking precautions.

I'm telling this story because I started researching c-spine clearance criteria when I got home this morning in an attempt to figure out if I had mis-managed my patient. I'm familiar with the NEXUS criteria, and honestly, that his the criteria I cited in my rational for not taking precautions. This morning I came across a few abstracts about the Canadian c-spine rule and how it is superior to NEXUS criteria. In turn, I researched the Canadian c-spine rule and reclassified my patient based on that criteria while doing a little call review with myself.

After all of that, here is my question (finally ): Would this particular case be consistent with the "bicycle struck or collision" part of the dangerous mechanism? I understand it technically was a bicycle collision, but this man probably would have hurt himself more falling to the ground. The car hood likely broke his fall from the bike and probably kept him from more significant injuries.

Secondly, how many of you would or would not have immobilized the above patient and why?

I know the outcome of the patient, and I'll post it after some feedback. Thank you all for your help.

Edited October 13, 2009 by EMS49393

[Just Plain Ruff]

I ran a call last night in which a bicyclist and a car collided at an intersection at a low rate of speed. By low, I mean the car had traveled three feet from a dead stop before coming in contact with the bicyclist. The speed would have likely been well below 5 mph. The patient was alert, oriented, and had a complaint of "a tired feeling" in his lower thoracic spine area. He had some minor redness to this area that resembled his mesh undershirt. He was ambulatory at the scene and initially wanted to refuse treatment and transport. He had no distracting injuries, no c-spine tenderness, no neurological deficits, no loss of consciousness, and was wearing a helmet as well as a few layers of protective clothing. He states he more or less tipped onto the hood of the car landing on his back. He was NOT thrown into the air, and had contact with the car that probably had less impact than if he would have fallen to the ground from a standing position. No damage to the car or the bike. His vital signs remained well within his normal limits throughout transport. We did not immobilize the patient. My third rider felt the patient didn't require spinal precautions and I agreed based on all the information I gathered. When we got to the ER and gave report to one of the residents, he ordered spinal precautions on the patient. The nurse also decided to give my third rider a hard time over not taking precautions.

I'm telling this story because I started researching c-spine clearance criteria when I got home this morning in an attempt to figure out if I had mis-managed my patient. I'm familiar with the NEXUS criteria, and honestly, that his the criteria I cited in my rational for not taking precautions. This morning I came across a few abstracts about the Canadian c-spine rule and how it is superior to NEXUS criteria. In turn, I researched the Canadian c-spine rule and reclassified my patient based on that criteria while doing a little call review with myself.

After all of that, here is my question (finally ): Would this particular case be consistent with the "bicycle struck or collision" part of the dangerous mechanism? I understand it technically was a bicycle collision, but this man probably would have hurt himself more falling to the ground. The car hood likely broke his fall from the bike and probably kept him from more significant injuries.

Secondly, how many of you would or would not have immobilized the above patient and why?

I know the outcome of the patient, and I'll post it after some feedback. Thank you all for your help.

'Car 3000 pounds, biciclyst(sic) 200 pounds. Pretty good mechanism even at 5mph with a cyclist with no protective clothing or equipment.

I would have boarded and collared him unless he refused.

I suspect you had a patient with a thoracic spine fracture right?

[EMS49393]

The car hit the bike tire and did no damage. If the patient would have fallen off to the right he would have hit the ground, he fell off to the left landing on the car.

He did have protective equipment, but I understand the 3000 lb car vs any protective gear will win.

The way the patient described the accident, he wasn't directly struck, his bike was, but he did fall off the bike.

Forgive my jumbled mess. I'm a night-shifter that is having trouble sleeping right now, so I'm not as eloquent as I like to be.

I'll PM you with the outcome. I really want to see more feedback before I post it. I'm really attempting to use this call to improve my assessment and comfort level with trauma patients. A person can't improve if they can't recognize that they may need to do something better.

[P_Instructor]

Criteria or not, if you suspect the potential for a thoracic spinal injury, immobilize. You cannot completely rule out a fracture even with the best criteria against it. Without a patient refusal, board the gourd and transport.

[JPINFV]

Question for the original poster, was an unstable spinal fracture found in the patient or not?

[cosgrojo]

The one thing that jumps out at me is that the patient was complaining of "a tiredness in lower thoracic area." This is not a normal sensation, one that would perk my interest. In the area that I was trained for c-spine rule out... any direct complaint to the head, neck or back automatically get a board. Granted that "tiredness" is not something that we associate with pain, it is significantly different from what we would expect to hear as a complaint. Distracting injuries only play a role if he has no complaints of pain to his head/neck/back. Did he say that this tiredness was a chronic condition that he had even before the collision? I suspect the answer to that question is no... so how did P-instructor phrase it... board that gourd.

[EMS49393]

The patient believed the sensation he was feeling in his back was a result of his riding. He was one week into a 3 month bike ride from one end of the US to the other. He is riding about 60 miles a day. He felt he might have just been physically fatigued because he was near his stopping point for the day.

He had no fractures. He was diagnosed with the ever generic sprain/strain to the back in the low thoracic/high lumbar area. He was discharged a few hours after arriving to the ER.

Thanks to those that replied.

[cosgrojo]

The patient believed the sensation he was feeling in his back was a result of his riding. He was one week into a 3 month bike ride from one end of the US to the other. He is riding about 60 miles a day. He felt he might have just been physically fatigued because he was near his stopping point for the day.

He had no fractures. He was diagnosed with the ever generic sprain/strain to the back in the low thoracic/high lumbar area. He was discharged a few hours after arriving to the ER.

Thanks to those that replied.

If the feeling was a semi-chronic condition that he had felt before... than I probably would not have boarded either. If it was a new feeling that the patient "thinks" is fatigue based on his 60 mile a day biking habit, I probably board. Thank you for posting your experience.

Just this morning I should have boarded someone that I didn't... it is a suck feeling when you think you might have messed up, but are not sure. Weird thing is, in my case, nobody asked me why I didn't board... I think I'm the only one who even thought I should have.

[EMS49393]

I'm never going to get it 100% correct, but that doesn't mean I'm going to stop striving for that 100%. It was an odd little call that really got me second guessing myself. Even after knowing the outcome, I'm still unsure I did the right thing. What I feel I have learned is that the general consensus is to immobilize no matter how "insignificant" a collision like that may seem. Next time I'll be more on my game because of what happened last night. I really appreciate the fact that you guys did not beat me up over this. I wondered if I should have posted it at all, and now I'm glad I did.

[AnthonyM83]

It's a hard decision sometimes, especially when doctors and nurses ask why he's in c-spine (after already hearing mechanism and patient s/s). And all this discussion about over c-spining without thought and NOT doing things just to CYA, rather because you have a good medical reason.

The criteria of "suspicion of possible fracture" is almost useless by itself, because it's so subjective. Anything could possibly fracture a back, yet we pick ourselves up after falls all the time, because common sense says we're fine.

I understand the predicament, but have no good advice.