ASA and NTG or no?

[scubanurse]

I know most hospitals won't take you to L&D until you're 23 or 24 weeks since before then there really isn't much they are going to do as baby isn't viable... just saying.

[triemal04]

Mikey, with all due respect, and not meaning to be insulting, but I have to ask this.

How old are you? From the content of your older posts I figured that 1984 was the year that you became a paramedic, or maybe started in EMS. With a lot of what you've been posting recently, I have to ask: is that actually your birthdate?

Because a lot of what you've been talking about, if you'd really been involved in EMS for that long, even if you only kept up on current medical practices in a cursory way, you'd know was wrong.

[rock_shoes]

Sorry. I hate it when people introduce new abbreviations without defining them.

Spinal Motion Restriction.

Just another way of saying "take c-spine". Implicit to the term is the idea that you can't immobilise the c-spine short of surgical fixation, just that you're trying to reduce movement, i.e. not everyone needs to be on a long board, not everyone needs to be supine, and a collar isn't a halo.

Interesting discussion.

I don't see the need to take this person to a center with cathlab, CT-angio, neuro-ICU or trauma services.

It would be a good idea to aim towards a site with inpatient beds and a CT.

There's not much information available here to guide this decision. Common things being more likely, I wonder if, in the end, our fellow might not have a touch of the pneumonia, and be a little dehydrated, weak and/or orthostatic.

The definitions are truly changing with regard to spinal precautions. Alberta Health Services EMS for example has pulled spine boards from continued use during transport. A spine board can be used to move the patient as needed but once on the cot the board is removed and the patient is transported on the cot mattress with a collar and head motion restriction (blocks or some other device to reduce lateral and rotational movement during transport. It's a progressive evidence based change on their part and I'm chomping at the bit to see other services follow suit.

[triemal04]

The definitions are truly changing with regard to spinal precautions. Alberta Health Services EMS for example has pulled spine boards from continued use during transport. A spine board can be used to move the patient as needed but once on the cot the board is removed and the patient is transported on the cot mattress with a collar and head motion restriction (blocks or some other device to reduce lateral and rotational movement during transport. It's a progressive evidence based change on their part and I'm chomping at the bit to see other services follow suit.

That's different, and seems a little counter-intuitive. Can elaborate a little more? Gurney straps don't do a super job of stopping side to side motion, and it seems like restricting how the head can move while allowing the body to move freely (or more freely anyway) would actually increase the potential risk.

[paramedicmike]

So no LSB for transport but a collar and blocks are in place? That doesn't make much sense. I'll second the request for clarification.

[systemet]

So, as I understand the concept, it's not about removing the LSB completely. They still remain in use for intubated patients, combative patients, and those you can't communicate with. The idea, is that conscious, cooperative people will splint their own necks. Further, the application of a traditional LSB/blocks/collar restriction carries some real risks for the patient, with little or no proven benefit.

* It takes relatively little time on an LSB to cause pressure ulceration. Most trauma patients are already at increased risk.

* Traditional spinal restriction results in a 20% decrease in FRC, which could become a trigger for pre-hospital RSI.

* Spinal immobilisation can complicate airway management, and increases ICP.

* The LSB is a relatively poor device for spinal "immobiilisation", as you're trying to force a curved structure to conform to a rigid plane.

* Healthy volunteers often develop neck pain, and report moderate-to-severe pain when immobilised on an LSB, which can result in unnecessary imaging, which carries costs and risks to the patient.

I think the rolls/blocks are primarily there to remind the patient not to move their head. Which is pretty much what they do on an LSB, anyway. I think we're all aware that a patient can generate substantial joint motion while immobilised.

There's also the question as to how great the benefit really is with traditional techniques. Only a very small percentage of patients that are immobilised by EMS have c-spine fractures. The vast majority of these are stable fractures. Even most of the radiographicaly "unstable" fractures are not grossly unstable, as in the patient will move their head and displace their c-spine. They're unstable in the sense that it would be unwise to discharge them home, to play soccer or football without addressing the injury. Even when injury does occur in a patient that presents neurologically intact, it's difficult to know whether this is from motion during their care or the natural progression of the initial insult, e.g. cord contusion/concussion. There's a certain argument that the force required to fracture the c-spine is many magnitudes of order greater than any force the patient may apply through voluntary movement of their neck.

Also, consider the care provided in the ER, where often the patient is removed from the LSB prior to radiography, and left supine with instruction not to move their head. Even after an injury is identified, it's not like the patient is immediately put back on an LSB and then halo'd. They're basically put on a soft stretcher, and told not to move their head, and log rolled by staff. That's all this really Is. It may be a change in care for EMS, but it's not really a divergence from standard care in the ER.

The patients that are combative are still on the LSB --- and these are the patients the ER typically leaves on, right? Because we're using it as a restraint device as much as anything else. The patients that are intubated are still on the LSB -- they can't splint, and tube displacement is a potential disaster. The patients that are significantly altered, or who can't follow instructions due to a cognitive issue or language barrier, they're still on the LSB too. But what's happening, is there's a recognition of the limitations of the LSB, and that "immobilisation", is a fantasy -- what we're doing is restricted motion. This can be accomplished in a number of different ways, which can be tailored to the patient.

[rock_shoes]

So, as I understand the concept, it's not about removing the LSB completely. They still remain in use for intubated patients, combative patients, and those you can't communicate with. The idea, is that conscious, cooperative people will splint their own necks. Further, the application of a traditional LSB/blocks/collar restriction carries some real risks for the patient, with little or no proven benefit.

* It takes relatively little time on an LSB to cause pressure ulceration. Most trauma patients are already at increased risk.

* Traditional spinal restriction results in a 20% decrease in FRC, which could become a trigger for pre-hospital RSI.

* Spinal immobilisation can complicate airway management, and increases ICP.

* The LSB is a relatively poor device for spinal "immobiilisation", as you're trying to force a curved structure to conform to a rigid plane.

* Healthy volunteers often develop neck pain, and report moderate-to-severe pain when immobilised on an LSB, which can result in unnecessary imaging, which carries costs and risks to the patient.

I think the rolls/blocks are primarily there to remind the patient not to move their head. Which is pretty much what they do on an LSB, anyway. I think we're all aware that a patient can generate substantial joint motion while immobilised.

There's also the question as to how great the benefit really is with traditional techniques. Only a very small percentage of patients that are immobilised by EMS have c-spine fractures. The vast majority of these are stable fractures. Even most of the radiographicaly "unstable" fractures are not grossly unstable, as in the patient will move their head and displace their c-spine. They're unstable in the sense that it would be unwise to discharge them home, to play soccer or football without addressing the injury. Even when injury does occur in a patient that presents neurologically intact, it's difficult to know whether this is from motion during their care or the natural progression of the initial insult, e.g. cord contusion/concussion. There's a certain argument that the force required to fracture the c-spine is many magnitudes of order greater than any force the patient may apply through voluntary movement of their neck.

Also, consider the care provided in the ER, where often the patient is removed from the LSB prior to radiography, and left supine with instruction not to move their head. Even after an injury is identified, it's not like the patient is immediately put back on an LSB and then halo'd. They're basically put on a soft stretcher, and told not to move their head, and log rolled by staff. That's all this really Is. It may be a change in care for EMS, but it's not really a divergence from standard care in the ER.

The patients that are combative are still on the LSB --- and these are the patients the ER typically leaves on, right? Because we're using it as a restraint device as much as anything else. The patients that are intubated are still on the LSB -- they can't splint, and tube displacement is a potential disaster. The patients that are significantly altered, or who can't follow instructions due to a cognitive issue or language barrier, they're still on the LSB too. But what's happening, is there's a recognition of the limitations of the LSB, and that "immobilisation", is a fantasy -- what we're doing is restricted motion. This can be accomplished in a number of different ways, which can be tailored to the patient.

Bingo. Here's a link to the memo notifying AHS field staff of the change.

http://www.associatedambulance.com/wp-content/uploads/2014/10/AHS-Memo-Spinal-Motion-Restriction-October-2014.pdf

What the memo doesn't go into is the use of a scoop stretcher to enable easier patient removal onto a cot or hospital bed. This would be considered acceptable as a scoop (double clasp variety) is considered to be an acceptable spinal motion restriction device in Alberta. I suspect the scoop was left out of the memo because most AHS staff still use a long spine board.

[BAYAMedic]

I purchased 2 CombiCarrier II backboards this spring for this exact reason. Still function as a LBB if "needed" but allow you to use the same muscle memory to board a patient, (no one up here had used clamshells) and two clasps later they are off the board and on the cot mattress. The big downside was the cost at just over $800USD each.

BayaMedic

[triemal04]

I get not using a longboard; that's great and in line with current trends and knowledge.

It's this part that has me confused:

Following removal of the long board, the patient must be log rolled onto their back, secured to the stretcher, and modified spinal protection, using a rigid collar and towel rolls/head blocks must be used to maintain spinal motion restriction.

Why not just use the c-collar? It's mentioned earlier in the memo that a collar and being told to lay still provides adequate protection; why add in another piece that could, if I'm reading that right and the blocks are meant to actually stabilize the head, actually create more harm?

[rock_shoes]

I get not using a longboard; that's great and in line with current trends and knowledge.

It's this part that has me confused:

Why not just use the c-collar? It's mentioned earlier in the memo that a collar and being told to lay still provides adequate protection; why add in another piece that could, if I'm reading that right and the blocks are meant to actually stabilize the head, actually create more harm?

I was a little confused by that part myself. I think the intention is to use them as a reminder for the patient not to move their head around. Basic towel rolls add almost no mass about the patient's head so the risk of secondary injury as a result of their use is relatively low.