3 ft fall spinal immobolization

[island emt]

You know I fell on the ice this morning, I hurt my Butt pretty bad, had the ambulance called for me this am because I could barely get up and some foreign idiot called EMS, They wanted to fully immobilized me because they said I had a distracting injury of butt pain and they couldn't rule out a spinal injury.

Since you landed on your derriere ::: they could have suspected a brain injury.

[Just Plain Ruff]

I do feel less smart today

[DwayneEMTP]

Secouriste, I'm not sure what the science says, so I'm only speaking for myself. But if vacuum mattresses were commonly used by most my guess would be that this would be a completely different conversation. Know what I mean? We can't, or at least I can't, really compare a vacuum mattress to a straight backboard, the mattress being by far the superior choice. (My unscientific opinion only.)

I am curious though if immobilization via vacuum mattress has been studied when compared to no board and the cot mattress only?

[Secouriste]

Well, in my view the VM offers a better immobilization and better protection. It is also more comfortable for the pt. The only problem with it is maneuvering in very narrow staircases (you know, the ones where the pt ends up in a vertical position), because it is not as rigid as it should. In those cases we have to attach the VM to a backboard and grab the backboard for the maneuver. Also, using a scoop stretcher to put the pt on the VM makes things much easier.

In my service, we tend to prefer using the VM, but it takes more time to immobilize the pt than a backboard. So if we're in the street of a not-so-secure neighborhood we'd rather use the backboard.

[systemet]

Let's give this "paramedic" the benefit of the doubt and say he properly applied the NEXUS criteria (although the fact that the pt got a CT in the ER makes me doubt this), don't forget, the NEXUS criteria are only 99.6% sensitive, meaning you are going to miss that 0.4% of clinically significant spine injuries. The Canadian cspine rule has a sensitivity of 100%, so if applied properly you shouldn't miss any. Like I said in an earlier post, for the original pt, as presented NEXUS says no and CCSR says yes.

As a paramedic, I find this debate very interesting. There's an obvious disparity between practice in the US / Canada, and in Europe/Aus/NZ. In North America, there's a far greater percentage of patients receiving SMR, they're more likely to be transported on a backboard versus a scoop or vacuum mattress, and very unlikely to be transported in just a C-collar in semi-Fowler's, or have their spinal restriction removed prior to a physician assessment.

I haven't read the studies that these numbers come from. Perhaps I should. But when I see numbers llike 99.6% and 100% being compared, I have to wonder, what are the n-values and CIs associated with each? What's the power analysis of the studies that have been performed? What is their alpha error? I do recall reading that CCSR is more sensitive versus Nexus.

From a clinical perspective, I think there's a big difference between a "c-spine fracture", and an "unstable c-spine fracture". I wonder how many of these 0.4% were patients that required a halo, or surgical fixation? How many wiere at risk for cord injury? I'm sure you've seen plenty of people present several days after an injury that's resulted in a vertebral fracture without a negative outcome.

In practice, using something resembling CCSR, I've always thought that the assessment of whether a potential mechanism of injury exists to be extremely subjective. If you don't have a potentially significant mechanism, then the rule isn't used. A simple ground level fall onto a soft surface might not be a major concern in a 20 year old who has syncope'd, or tripped over their own feet, but is a different issue in a kyphotic 80 year old with a hx of long-term steroid use.

At what point is the process of immobilisation and clearance too cumbersome, and too inefficient a use of very scarce and expensive resources? Tort damages in the US essentially mandate very conservative practices, where some other areas have limited liability or face lesser mean damages. There is a great variance worldwide, even in industrialised nations, in how c-spine immobilisation and clearance is performed, which is interesting when one considers that ultimately everyone is trying to do their best for the patient.

As a paramedic, I find this debate very interesting. There's an obvious disparity between practice in the US / Canada, and in Europe/Aus/NZ. In North America, there's a far greater percentage of patients receiving SMR, they're more likely to be transported on a backboard versus a scoop or vacuum mattress, and very unlikely to be transported in just a C-collar in semi-Fowler's, or have their spinal restriction removed prior to a physician assessment.

I haven't read the studies that these numbers come from. Perhaps I should. But when I see numbers llike 99.6% and 100% being compared, I have to wonder, what are the n-values and CIs associated with each? What's the power analysis of the studies that have been performed? What is their alpha error? I do recall reading that CCSR is more sensitive versus Nexus.

From a clinical perspective, I think there's a big difference between a "c-spine fracture", and an "unstable c-spine fracture". I wonder how many of these 0.4% were patients that required a halo, or surgical fixation? How many wiere at risk for cord injury? I'm sure you've seen plenty of people present several days after an injury that's resulted in a vertebral fracture without a negative outcome.

In practice, using something resembling CCSR, I've always thought that the assessment of whether a potential mechanism of injury exists to be extremely subjective. If you don't have a potentially significant mechanism, then the rule isn't used. A simple ground level fall onto a soft surface might not be a major concern in a 20 year old who has syncope'd, or tripped over their own feet, but is a different issue in a kyphotic 80 year old with a hx of long-term steroid use.

At what point is the process of immobilisation and clearance too cumbersome, and too inefficient a use of very scarce and expensive resources? Tort damages in the US essentially mandate very conservative practices, where some other areas have limited liability or face lesser mean damages. There is a great variance worldwide, even in industrialised nations, in how c-spine immobilisation and clearance is performed, which is interesting when one considers that ultimately everyone is trying to do their best for the patient.

As an aside, I quite like this document from the UK:

http://www.fphc.co.uk/content/Portals/0/Documents/2013-12%20Spinal%20Consensus%20COMPLETE.pdf

It seems quite progressive. I would like to hope that one day my practice could more closely resemble this.

[ERDoc]

Here is the NEXUS study:

http://www.nejm.org/doi/full/10.1056/NEJM200007133430203

And here is the CCSR study:

http://www.ncbi.nlm.nih.gov/pubmed/11597285

The NEXUS had an N=34069 and CCSR N=8924, I'll let you have a look through the rest of the stats so we don't clog up the thread. You are correct, there are stable cervical spine fxs. Pts in the NEXUS study ranged from <1y/o to 101y/o while CCSR uses an age over 65y/o as a high risk criteria. You are also correct about how cumbersome something is. The whole reason for designing clinical decision tools such as these is so that they are easy to use in the real world. If you have some monstrosity of an algorithm it is a useless tool.

[Just Plain Ruff]

How the hell does a less than one year old get a C-spine fracture? Just aint natural. Pts in the NEXUS study ranged from <1y/o

[scubanurse]

High impact MVC w and an improperly restrained (front facing) car seat...

[Secouriste]

I think that abuses like "shaking" can cause that sort of problem too (correct me if I'm wrong).

[Just Plain Ruff]

Mine was a rhetorical comment, we all know the causes of a less than one year old with a c-spine fracture but of those causes, they should really never happen if we are truly really careful or non-physical with a child. It was just a shake my head moment.