C-Collar only immobilization

[croaker260]

So, we have finaly started it. We pulled the trigger and now have a protocol for SSI (Which we have had for about 12 years...but under the old protocol, those we immobilized we did with full immobilization) . Under the new protocol...those we still immobilize (unless major trauma) we are only immobilizing with a c-collar. We are only using the LSB for extrication. Also, in training, the emphasis is to use the scoop instead when possible.

About 10 years overdue if you ask me.

Anyway, here is our protocol if your interested. its pretty simple.

For what its worth, we are strongly considering dropping to only two boards and adding a second scoop stretcher for this.

-Steve

Appendix: Q

TITLE: Selective Spinal Immobilization Protocol

REVISED: June 10, 2013

1. BACKGROUND:

This protocol is intended to allow selective exclusion of full spinal immobilization

in patients with a low index of suspicion for spinal injury and to use the long spine

board and/or scoop stretchers for extrication purposes only.

2. PROCEDURE:

Cervical Spine:

In order for providers to defer cervical spine immobilization (i.e. the c-collar) in patients

with mechanical potential for injury, ALL of the following criteria must be met and

individually documented.

1. No posterior neck pain or tenderness.

2. No intoxication.

3. A normal level of alertness.

4. No focal neurologic deficit.

5. No painful distracting injuries.

Note: For elderly patients >65y/o, patients with any underlying baseline mental

dysfunction such as dementia or other chronic neurologic conditions, rheumatoid

arthritis, chronic steroid therapy, severe osteoporosis or who are chronically

bedridden, higher levels of concern for cervical spine injuries are warranted and

lower thresholds for using a c-collar should be instituted.

Note: Axial loading of cervical spine is not recommended.

Thoracic and Lumbar Spine:

The long spine board is intended as an extrication device and should be

considered as such. When at all possible, the scoop stretcher and/or KED

devices should be used to move the injured patient to the stretcher and removed

as soon as possible.

For any patient with:

1. No tenderness of midline upper, mid or lower back.

2. No intoxication.

3. A normal level of alertness.

4. No neurologic deficit or incontinence.

5. No painful distracting injuries.

If the above criteria are met, then extricate/assist the patient to the stretcher with

the least manipulation of the spine as possible.

If the patient has any of the above: utilize the appropriate transfer/extrication

device (long spine board, KED, slider board or scoop stretcher) to move patient

to the stretcher that will cause the least amount of mobility of the back.

Once the patient with suspected/known back injury is placed on the stretcher,

remove the extrication device as soon as safely possible and keep the patient in

the supine position for transport/transfer to the appropriate destination.

Any further transfers of the patient with a known or suspected spinal injury should

be done with a slider board observing precautions not to manipulate the spine.

Physician PEARLS:

In patients at extremes of age, a normal exam may not be sufficient to rule out

spinal injury.

Padding (inflatable mattress, towel rolls, etc.) is recommended when appropriate

for patient comfort.

Posterior bony cervical-spine tenderness is present if the patient reports pain on

palpation of the midline neck from the nuchal ridge to the prominence of the first

thoracic vertebra or if the patient has pain with direct palpation of any cervical

spinous process.

Patients should be considered intoxicated if they have either of the following:

1. A history provided by the patient or an observer of intoxication

or recent ingestion of alcohol or other mind altering substances such

as benzodiazepines, narcotics or recreational drugs.

2. Evidence of intoxication on physical examination such as an odor of

alcohol, slurred speech, ataxia, dysmetria, or other cerebellar findings

or behavior consistent with intoxication.

An altered level of alertness can include any of the following:

- A Glasgow Coma Scale score of 14 or less.

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

- A delayed or inappropriate response to external stimuli, or other findings.

[island emt]

Steve: Maine has has a selective spinal immobilization protocol in place for about 12 years. It originally came from the Wilderness medicine folks and was fine tuned after the NEXUS study.

It is similar to what you posted and the newest update due this fall is leaning towards less reliance of long boards as an immobilization requirement.

Last time I attended a conference on this, EMS's correct application following the protocol had very few missed spinal FX;s on par with the ER's using radiographic review.

Criteria are very similar to yours.

I believe our protocols are now posted on the Maine EMS website along with a draft copy of this years updates.

Ed

[Doczilla]

I've been heavily involved with this in our state and elsewhere. SSI has been around for a long time, but where we are changing the thinking is in not having the patient remain on the backboard once moved from point of injury to the stretcher. I've had emails from several states asking for our protocols, clinical justification, and training materials. NAEMSP came out with a position paper on it last year as well. The original position paper was pretty strongly worded about doing away with the LBB as much as possible, but a consensus document with ACS-COT was created, and it was softened to get buy-in from the surgeons. Some have gone on a system wide basis, while others are doing it at the state level. It's been very well accepted, and I'm getting emails on the ACEP EMS list indicating that more areas are doing it. It's widespread enough now that adopting the protocol is no longer "outside" the usual care, but an accepted practice.

It's a tide, hopefully for good.

'zilla

[HellsBells]

Very Encouraging, I hope to see the trend continue in this direction.

[HarryM]

That's awesome. Trust me, it will lead to a lot less work immobilising a lot of patients and also increase comfort for your patients!

[MikeEMT]

We do C-collar only immobilization all the time. We don't have protocol for it though, usually its because fire will give us a patient and say "oh its a ground level fall with some foot pain" we get them in the ambulance and they complain of head or neck pain.

I don't know how I feel about backboards. I think they have their purpose but i'm not sure they are used appropriately.

[medicgirl05]

From personal experience, there is no way I could have been on a backboard when I broke my back. I loaded myself into the car in a bent over position to get to the ER for some pain relief. Since then I absolutely hate putting patients on a backboard.