Scientific evidence against longboards.

[DwayneEMTP]

Hey,

While in Sydney I was talking to one of the medical directors about LBBs.

I made the argument that it was relatively common knowledge that LBBs were not only not useful as a spinal precaution, but that there seemed to be evidence that they caused damage to many people, by many different mechanisms.

She had never heard this line of thought before and challenged me to back it up with research. Here in PNG my internet is super expensive so I can't really afford to do much searching until I get onsite, so I thought that maybe you all could help me out?

The evidence needs to support the concept at the physician level. I'm sure it won't make any significant changes in protocols likely, but perhaps it will convince her/them that paramedics are concerned with actual issues as well as other cert levels.

Thanks for any help that you can provide...

Dwayne

[paramedicmike]

Dwayne,

I'm looking in between studying. Here's the first one I found comparing rates between two different hospitals in two different countries. The link takes you to the abstract but you can download the .pdf of the study from the page.

I'll keep looking as I can.

[paramedicmike]

Thought this one was interesting. It's essentially a lit review from 2007 showing that very few studies have been done on this topic.

For now, that's all I have. Gotta get some sleep. I'll be interested to see if anyone comes up with other info.

[mobey]

http://www.annemergmed.com/article/S0196-0644(95)70234-2/abstract

Although from '95, this one shows efficacy for padding to prevent pressure sores. Kind of a crappy one, but does speak to the damage we do.

A good question to ask is "Why did they start putting mattress pads on operating tables?" Always gets the juices flowing in the right direction.

[Doczilla]

I wonder who might have put that idea in your head?

¡Davis, et al: retrospective study of 32,117 trauma patients

§2.3% with c-spine injury

§10 patients with delayed dx of spinal injury AND permanent neurological sequelae

¡Gerrelts, et al: Review of 1331 trauma patients

§5 patients with delayed dx of cervical injury

§None with permanent deficit

¡Platzer et al: 347 with c-spine injuries

§Of the 18 with delayed dx, 2 had permanent deficit

¡Hauswald: 5 year retrospective review

§NM vs. Malaya

§The difference: Malayan patients had less frequent deterioration and less overall neuro disability

§Small numbers, different mechanisms

¡Neuro decompensation occurs in 5% anyway

¡Spinal immobilization raises ICP 4.5 mmHg

¡MILS led to failed airway in 50% after 30 seconds vs. 5.7% without

¡Gruen, et al: Trauma mortality in 44, 401 patients. 2594 deaths, errors in 64.

§Failure to secure an airway in 16% of those

¡Santoni: MILS doubles force necessary for intubation

¡Totten, et al: LBB or vacuum mattress restricted respiration by 15%

¡Bauer, et al: LBB limits respiratory function

¡Respiratory failure is COD in 6% of trauma patients

¡Hauswald: Substantial force required to injure spinal cord

§Post-injury movement probably not sufficient

¡Pain scale: 9.7 vs. 3.7cm on pain scale with LBB vs. LBB with air mattress

¡76% reporting pain after 60 min

¡15% with point tenderness of spine after 30 min, 25% after 60 min

¡18/20 reported increasing pain and discomfort

Cordell WH, Hollingsworth JC, Olinger ML, Stroman SJ, Nelson DR. Pain and tissue-interface pressures during spine-board immobilization. Ann Emerg Med. 1995 Jul;26(1):31-6.

Lerner EB, Billittier AJ 4th, Moscati RM. The effects of neutral positioning with and without padding on spinal immobilization of healthy subjects.

March JA, Ausband SC, Brown LH. Changes in physical examination caused by use of spinal immobilization. Prehosp Emerg Care. 2002 Oct-Dec;6(4):421-4.

¡3 times more likely to develop pain with LBB than vacuum mattress

¡Trunk movement still significant; no method with a LBB eliminates motion

Chan D, Goldberg RM, Mason J, Chan L. Backboard versus mattress splint immobilization: a comparison of symptoms generated. J Emerg Med. 1996 May-Jun;14(3):293-8.

Perry SD, McLellan B, McIlroy WE, Maki BE, Schwartz M, Fernie GR. The efficacy of head immobilization techniques during simulated vehicle motion. Spine (Phila Pa 1976). 1999 Sep 1;24(17):1839-44.

¡101 blunt trauma patients with c-spine injuries

¡87% had “distracting” injuries

§rib fractures, lower and upper extremity fractures

¡4% had no tenderness on c-spine

§All 4% had bruising and tenderness of anterior chest

Konstantinidis A, Plurad D, Barmparas G, Inaba K, Lam L, Bukur M, Branco BC, Demetriades D. The presence of nonthoracic distracting injuries does not affect the initial clinical examination of the cervical spine in evaluable blunt trauma patients: a prospective observational study. J Trauma. 2011 Sep;71(3):528-32.

¡Log roll creates unacceptable motion

¡Lift and slide technique creates less motion

¡Scoop stretcher may be better as well

Horodyski M, Conrad BP, Del Rossi G, DiPaola CP, Rechtine GR 2nd. Removing a patient from the spine board: is the lift and slide safer than the log roll? J Trauma. 2011 May;70(5):1282-5; discussion 1285.

Del Rossi G, Horodyski M, Heffernan TP, Powers ME, Siders R, Brunt D, Rechtine GR. Spine-board transfer techniques and the unstable cervical spine. Spine (Phila Pa 1976). 2004 Apr 1;29(7):E134-8.

Del Rossi G, Rechtine GR, Conrad BP, Horodyski M. Are scoop stretchers suitable for use on spine-injured patients? Am J Emerg Med. 2010 Sep;28(7):751-6. Epub 2010 Feb 25.

¡Twice the mortality rate if immobilized (14.7 vs. 7.2%)

¡0.01% had incomplete neurological injury and underwent fixation

¡NNT: 1032

¡NNH: 66

Haut ER, Kalish BT, Efron DT, Haider AH, Stevens KA, Kieninger AN, Cornwell EE 3rd, Chang DC. Spine immobilization in penetrating trauma: more harm than good? J Trauma. 2010 Jan;68(1):115-20; discussion 120-1.

¡18/30 interfac transport services immobilized for transfer, even if cleared by sending ER MD

¡Additional 4/30 immobilized unless cleared radiographically

¡No services moved pts to softer surface if known to have injury

¡

¡51% reported no neck or back pain at scene

¡13% not even asked about neck or back pain before FSI

Hauswald M, McNally T. Confusing extrication with immobilization: the inappropriate use of hard spine boards for interhospital transfers. Air Med J. 2000 Oct-Dec;19(4):126-7.

McHugh TP, Taylor JP. Unnecessary out-of-hospital use of full spinal immobilization. Acad Emerg Med. 1998 Mar;5(3):278-80.

[BAYAMedic]

Hmm 'Zilla... Seems to me like that looks like a cut and paste off of a powerpoint I saw once....

Fireman1037

[Doczilla]

Hmm 'Zilla... Seems to me like that looks like a cut and paste off of a powerpoint I saw once....

Yup! And Dwayne too...

No reason to duplicate work.

[croaker260]

As you may or may not be aware, Dr. Wesley has done a lot of work on this, his webpage is here http://emsunited.com/profile/KeithWesley

ANd of course a wonderful article he wrote is here...

http://www.sehsc.org/news/cspine.htm

I have a study from canada somewhere that looks at the incidence of clinically significant pain and other sequla from LSBs, but it may take a bit.