Backboarding policy change

[krumel]

Nice memo and for sure a one very well thought of...

Just an observers notice: Have of the world who were using Scoops&vacuum matresses (or just scoops) by now have turned over to spineboards because they are "the good thing from the states".... I wonder what will happen nexxt... the US-Paras during to vacuum matresses?

[Just Plain Ruff]

Way to go doc. Upward battle but first steps are the hardest.

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[WestMetroMedic]

This is very welcome development... I first heard official-ish word of this development while taking a PHTLS course last year.

Instead of using a scoop stretcher, my service keeps using a technology we have used for 120 years of our existence, "canvas and poles." As archaic as it looks, this system is incredibly adaptable, ergonomically better than all other options, and markedly more comfortable for our customers. Essentially all it is, are 2 aluminum poles with wood handles that we have custom made that fit in a sheath on either side of the custom made canvas. the canvas covers are about $23 USD each and i think we get about 10 uses out of each cover before they are donated to the goodwill. In the MSP area, we have the luxury of having nearly every hospital use the same laundry service, so we just get them routed back to us after laundering. Excess of 500 pounds can be carried by these. We get a lot of crap from other services who don't realize how awesome these are, but they iz just haters.

[Kiwiology]

Interesting. I should say that a decision has been made in NZ to replace the scoop stretcher with the combi carrier but without the yellow head block thing.

[Doczilla]

UPDATE: We have implemented new policy on immobilizing patients, and I have copied the policy below. There is substantial room for EMT judgment. It went into effect about a month ago, so I thought I'd share the experience thus far.

The director and AD of Trauma thought it looked good. Our trauma team is pretty good about getting patients off of the backboard during the secondary survey and before any CT scans.

The medical director for our ER group liked it as well. We've had an internal ER policy in place for a year not where the medics and nurse get the patient off the board upon arrival at the hospital and before being seen by a physician. The competing hospital system has had such an ER policy for at least 2 years with very good success. Acceptance of this internal policy has been mixed. Some nurses are in favor, others nervous about it and unwilling to take the patient off the board, so they will just let the attending know that there is a patient on a board and to see them quickly so they can be removed from the board (easier at some times than others).

The EMS response has been interesting. The 2 agencies where we implemented it seem to like it quite a bit, but they tend to be fairly progressive services. There are some who have been teaching in the area, and response has been all over the map. Some medics think it's great. One chief stormed out of the room and said it would never be implemented at his service as long as he was there. Over his dead body, or something to that effect.

It seems to be the younger medics who like the policy more. A snide comment by one of the other local EMS medical directors: "The chance of endorsing this policy is inversely proportionate to the size of your prostate."

One hospital, a level III trauma center, initially pushed back very hard. As one doc said to the crew, "dumbest f&%#ing thing he'd ever heard." They initially said they would purchase backboards and reimmobilize any of our patients until the scans were done, but subsequently reversed their stance on it and are supportive. Another doc, from the same hospital, said it was "long overdue".

Another local agency (with which I have no involvement) has reviewed and adopted the policy.

We've had to tweak the policy a couple of times:

- The flight service has very strong feelings on immobilizing any patients they transport, and insist that it be done. I think this is not huge, partly because we hardly ever call them due to ground transport times of <30 min, and if we did, it would be for a critically ill trauma patient that is likely to remain on the board anyway.

- We had to put stronger emphasis on the multi system blunt trauma patient who cannot follow commands that should remain on the board.

- Initially the memo referred to use of the board for extrication, which to my mind meant "movement from point of injury", but was interpreted by some to mean only vehicle extrication. So this was clarified.

The medics have been very understanding of it as we adjust the policy and training based on their feedback. Nothing new is perfect the first time out, and they have been very patient.

'zilla

To: All Bigredtruck Fire Division Personnel

From: Doczilla, MD

Re: Change in spinal immobilization protocol

The following policy combines policy memo from July 6, 2012 and subsequent clarification from July 14, 2012 memo.

Substantial evidence now exists to show that long back boards may cause harm to patients, and no literature has yet shown a benefit of their use. Back boards do a horrible job of immobilizing the spine, and movement is worse on the backboard than on a soft surface that conforms to the patient.

• Patients who are alert enough to follow commands can typically maintain stabilization of their own spine without assistance.
  
• Backboarding increases mortality in certain trauma patients.
  
• Backboarding does nothing to prevent neurological complications from spinal injury.
  
• Backboarding restricts respiration, which some patients cannot tolerate.
  
• Backboarding rapidly leads to skin breakdown and pressure ulcers, even after a short period of time, and is particularly hard on the elderly.
  

Effective immediately, the following changes are to take place in our practices of spinal immobilization:

These patients may require immobilization with a cervical collar:

• High risk injury (high speed MVC, axial loading injury)
  
• Focal neurological deficits such as paralysis
  
• Intoxication or altered mental status
  
• Age >65
  
• Presence of midline bony tenderness of the spine
  
• Midline spinal pain with movement of the neck
  

Patients without any of the above findings may be transported without a cervical collar.

Selectively immobilize (with a cervical collar) only those patients at high risk for spinal injury as above or with clinical indications of spinal injury. Use the long spine board, scoop stretcher, vacuum mattress, short board, or Kendrick Extrication Device (KED) to minimize movement of the patient when moving them from the point of injury to the stretcher. Once the patient is moved to the stretcher, using log roll or lift-and-slide technique, lay the patient flat on the stretcher and leave the c-collar in place. Elevate the back of the stretcher as needed for patient comfort.

Do not transport a patient to the hospital on a backboard, short board, KED, or vacuum mattress unless it is necessary for patient safety. Patients who are markedly agitated and confused from head injury may not be able to follow commands with regard to minimizing spinal movement, and combativeness may also be a factor. Patients may remain on a backboard if the crew deems it safer for the patient, and this will be at the discretion of the crew.

A multi system blunt trauma patient, such as from a high velocity crash or significant fall, who is unable to follow commands due to combativeness, intoxication, or decreased mental status, should remain on the backboard for their safety until handoff to the ED.

Never immobilize a patient with penetrating trauma such as a gunshot wound or stab wound. Even with neurologic deficits caused by transection of the spinal cord, the damage is done; additional movement will not worsen an already catastrophic injury. Emphasis should be on airway and breathing management, treatment of shock, and rapid transport to a Level 1 or 2 trauma center.

If manual cervical stabilization is hampering effort to intubate the patient, the neck should be moved to allow securing the airway. An unsecured airway is a far greater danger to the patient than a spinal fracture.

Eliminate the "standing take-down" for backboarding patients who are ambulatory after an injury. Place a collar and allow the patient to sit on the cot, then lie flat. Patients who are ambulatory and able to follow commands do a better job of preventing movement of an injured spine than rescuers do.

Remove cervical collars on conscious patients that tolerate them poorly due to anxiety or shortness of breath.

Patients who are markedly agitated and confused from head injury may not be able to follow commands with regard to minimizing spinal movement, and combativeness may also be a factor. Patients should remain on a backboard if the crew deems it safer for the patient, and this will be at the discretion of the crew.

[The Helicopter Service] has requested that we fully immobilize on a backboard all blunt trauma patients transported by them, regardless of complaint. This is so they may remain consistent with their own policies on spinal immobilization.

The new protocol will:

• reduce pain and suffering
  
• reduce complications
  
• decrease on scene times
  
• reduce injuries to crews who are attempting to carry immobilized patients
  
• reduce unnecessary imaging costs and radiation exposure
  

Any questions about protocols or medical treatment may be directed to myself or Capt. Awesome.

Very respectfully,

Doczilla, MD FACEP

Medical Director

Bigredtruck Fire Division

Cc: Chief

[Kiwiology]

Very awesome mate, I am glad you are doing this, it is long overdue.

For your interest, here is the New Zealand wide guideline

3.7 CERVICAL SPINE IMMOBILISATION

Significant abnormalities within the primary survey always take priority over the cervical spine. The possibility of cervical spine injury should be considered in all patients suffering from trauma, except those with isolated peripheral injury. Patients suffering from trauma as a result of road crash (particularly if it involves roll over or ejection), or significant fall, or patients with pre-existing cervical spine abnormalities (such as rheumatoid arthritis) are particularly at risk.

If the patient has any one of the following signs or symptoms they should have their cervical spine immobilised:

a. Tenderness at the posterior midline of the cervical spine or

b. Focal neurological deficit or

c. Decreased level of alertness or

d. Evidence of intoxication or

e. Clinically apparent pain that might distract the patient from the pain of a cervical spine injury.

Clearing the cervical spine clinically

• The criteria described above may be used in children, provided the child is old enough to cooperate with having a history taken and being examined.

• Begin by taking a history:

a. Do they have neck pain?

b. Do they have numbness or tingling anywhere?

c. Do they have pain anywhere else?

• Next, examine the patient:

a. Feel for midline tenderness by palpating the posterior cervical spine from the skull to the prominence of the first thoracic vertebrae. Lateral muscular tenderness is not a sign of cervical spine injury.

b. Check they have normal sensation to light touch in their hands and feet.

c. Check they can move their hands and feet normally.

d. Look for signs of intoxication.

• The patient has a focal neurological deficit if they have any altered sensation or motor power (strength) in their limbs.

• The patient has a decreased level of alertness if they have any of the following:

a. GCS less than 15 or

b. Disorientation to person, place, time or events or

c. Short term memory loss or

d. Delayed or inappropriate response to external stimuli.

• Deciding if a patient has evidence of intoxication requires clinical judgement. In general, to have evidence of intoxication the patient must show some signs of a decreased level of alertness.

• Deciding if a patient has clinically apparent pain that might distract the patient from the pain of a cervical spine injury requires clinical judgement. To be considered distracting, the pain must be significant enough that it might prevent the patient from noticing their neck is sore.

• Use extra caution when clearing the cervical spine clinically if the patient is not in clinically apparent pain but has an injury that would normally be expected to cause pain. Examples include long bone

fractures and dislocations.

Immobilising the cervical spine

• Immobilisation must not impair the maintenance of an adequate airway, breathing or circulation.

• The most important part of immobilisation is the application of a correctly sized, well fitted hard collar. Getting the size and the fit right is very important and worth the extra time.

• Place the patient flat with their spine in a neutral position. For most adults in the supine position, this will require 3-4 cm of flat pillow or folded towel behind the head. If the patient is placed on their side, keep the spine in alignment.

• Clinical judgement is required for uncooperative patients. If attempts to immobilise the cervical spine result in the patient becoming agitated and/or uncooperative, it is sufficient to verbally discourage the patient from moving.

• All patients with a suspected cervical spine injury should be treated and transported in a flat position if possible, noting that:

a. Patients should be transported supine if they are obeying commands or have been intubated with an endotracheal tube.

b. Patients should be transported tilted on their side if they are not obeying commands or are vomiting.

c. Patients should be sat to 45 degrees if they have respiratory distress.

• Patients with an immobilised cervical spine may be transported directly on an ambulance stretcher, provided they are suitably restrained, with their spine in a neutral position.

• The head and shoulders must not be independently immobilised. If the head and shoulders are immobilised, the entire body must be immobilised.

Spine boards, scoop stretchers and combi-carriers

• Spine boards, and other rigid flat boards are primarily sliding and extrication devices.

• Scoop stretchers and combi-carriers are primarily lifting and carrying devices.

• All of these devices carry the risk of creating pressure areas if the patient is on them for longer than 30 minutes. If the patient is anticipated to be on the device for longer than 30 minutes, they should be removed from it prior to transport, provided this is feasible.

• If a patient is transported on such a device, they should be removed from it as soon as reasonably possible after arrival at hospital.

• If an immobilised patient is being transported on such a device, they require full body immobilisation with:

a. A well fitted cervical collar and

b. The head and body firmly restrained to the device and

c. Rolled towels or blocks placed alongside the head.

Prophylaxis of nausea and vomiting

• Prophylactic administration of ondansetron is not routinely required for patients with an immobilised cervical spine.

• Consider administering ondansetron if:

a. The patient has nausea or

b. The patient has a known history of motion sickness or

c. The nature of the patient's injuries and the transport position is such that vomiting would be particularly problematic.

Intubation

• The maintenance of an adequate airway and breathing always take priority over the cervical spine. If you have to intubate the patient to maintain airway and breathing then do so, even though this will mean the cervical spine is moved.

• Patients requiring intubation should have the front of their cervical collar undone during intubation. This allows for maximal mouth opening, which minimises cervical spine movement during intubation.

• Apply in line stabilisation, not traction, if you have an appropriately trained person available.

Edited July 28, 2012 by Kiwiology

[Bieber]

+100

Hallelujah!

We're going to selective spinal immobilization--thank god--but I anxiously await the day when we will say goodbye to death boards forever.

[rock_shoes]

I love the sensible direction you've chosen to take this doc. Long overdue.

Kiwi, I didn't see anything in the New Zealand guidelines about assessing for midline pain/tenderness while putting then through a range of motion exam.

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[Bernhard]

I sent the memo to two of the EMS agencies (fire based, as are most around here) where I work. We are attempting to effect a cultural shift for the benefit of our patients. I guess we will see if it takes hold.

Great effort!

I've taken the time now to collect our german standards in emergency medicine (there are no protocols here, but some general national treatment standards for medicine in all fields), citing them to support my case in getting rid of the spineboard as "always to use" treatment, like it seems to be seen by some colleagues here...

Thank you very much for the valuable input!

Some questions regarding your sources:

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.

Twice the mortality rate in penetrating trauma if immobilized (14.7 vs. 7.2%)

0.01% had incomplete neurological injury and underwent fixation

Number Needed to Treat: 1032

Number Needed to Harm: 66

I don't understand those numbers ("to Treat", "to Harm"), can you please explain what you tried to extract there?

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.

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

Bottom line: "distracting injuries" are largely a myth.

This I don't understand. When there ARE 87% of distracting injuries, why are they a myth?

However, I must admit, I didn't yet try to get hands on the original studies.

EDIT: is there any way to have your presentation for "myths in EMS" available?

Edited July 31, 2012 by Bernhard

[Doczilla]

I don't understand those numbers ("to Treat", "to Harm"), can you please explain what you tried to extract there?

The "number needed to treat" reflects the number of patients that will receive a treatment in order to create one good outcome. Few treatments benefit every patient who receives them. For example, cholesterol lowering drugs are known to help prevent heart attacks, but not 100% of the time. You will have to give hundreds of people the drug before you can say you have prevented one heart attack. A NNT of 1 means that everyone who receives the treatment lives, and everyone who doesn't (the controls) dies. For the spinal study, you have to immobilize over 1000 patients before you could theoretically prevent one bad outcome (doubtful that backboarding would even do so).

The "number needed to harm" is the same concept, only looking at bad outcomes. Say a treatment is very toxic, and there is a 5% mortality rate caused by the drug. For every 20 patients who receive the drug, one will die, therefore the NNH is 20. In the spinal immobilization study, you would only immobilize 66 people before you caused a bad outcome.

Taking the above numbers into account, if you immobilized 1032 patients with penetrating trauma, you might prevent 1 bad outcome, but cause bad outcomes in 15 others.

More on this calculation: http://en.wikipedia.org/wiki/Number_needed_to_treat

This I don't understand. When there ARE 87% of distracting injuries, why are they a myth?

A "distracting injury" is theoretical. The idea is that if you have a painful enough injury, such as a femur fracture or rib fracture, it may focus your mind so that you do not feel the pain in your neck from a spinal fracture, and you should therefore be immobilized until x-rays are performed. What the study showed was that of these patients with confirmed spinal injuries, 87% of them had other injuries that would meet their definition of potentially distracting. What they found was that even with these other injuries, all but 4 of the patients still had pain and tenderness in their neck. Of the 4 that did not, all 4 had tenderness and bruising of the anterior chest. It calls into question the theory of a distracting injury that would require x-rays of the neck on a patient who has no neck pain, or perhaps we should better define a distracting injury to include anterior chest tenderness.

'zilla

Edited August 4, 2012 by Doczilla