Spinal Immobilization: Are we doing more harm than good ?

[Ace844]

Selective immobilization is exactly what this criteria were discussing is about. One could extrapolate that by using the NEXUS spinal protocol, your selectively immobilizing patients.

Regarding some of your other posts from this thread.

1. EMS absolutely should NOT be determining patient transport destination by a trauma centers class designation. This is simple kids. Trauma centers get trauma patients. It is not within any of our scopes to determine if a patient is "OK for a level two" or is "FUBAR'd for a level one". I encourage everyone to do some reading on what is required of each level of facility, and note the differences. BUT, keep in mind, delaying care for a patient by bypassing a appropriately level 2 facility for a level one will only serve to...how did asys put it...

give a greasy haired lawyer another 1000 dollar bag of coke to snort off a hookers ass.

Yeah...thats it. That was soooo classic line of the year...but anyway...

2. Call it what you want, but calling a "trauma alert" to any hospital is a good idea. Til your patient is complete BS, and your service gets the 1k bill for activating the team jammed directly in a place where it hurts...just a thought. Think it doesnt happen? PM me, ill give you the cell of the chief of the department who just went through it.

3. Your statements thus far are bordering practicing medicine without a license. Heres the thing. Performing the NEXUS protocol is great. If you do it right, its an awesome tool. Bottom line is, WE CANT DO IT. Period. First doc who hears you did it and get a bug up his behind is going to hang you for it. Lets also remember, PA BLS protocols stipulate all patients involved in MVA's and are transported are to be immobilized. This, of course, was a avoidance of liability move by the DOH, but as soon as they find out your toying with NEXUS, this is the protocol they are going to DE-cert you with...and send you off to Micky D'z patented burger flipper school.

4. Mike speaks of selective immobilization. Great idea. Err on the side of caution, and hope for the best. Not everyone needs a LSB. Everyone just keep in mind it only takes one time for a mistake in judgement to put us in the burger flipper class with commodore here.

Ok...thats all i got. Thanks for listening.

PRPG

Well said Brotha...

Additionally "MedicMike & Scar" as well 8)

[Ace844]

(Air Medical Journal

Volume 25 @ Issue 4 , July-August 2006, Pages 144-148

Pediatric Perspective

Current practice in pediatric immobilization—an editorial

Christopher Wagner RN, CFRN, EMT-P1 and Paul Mazurek RN, BSN, CCRN, CEN, EMT-P1

Available online 1 July 2006.)

As a member of the editorial board of Air Medical Journal, as well as the pediatric section editor, I have the unique opportunity to be afforded a forum in which to discuss areas of practice that are controversial and, in many cases, heatedly debated. A current focus of debate is the appropriate prehospital and transport spinal immobilization of the pediatric patient. Perhaps no other commonly performed treatment is more poorly researched or clouded by practitioners' long-held anecdotal and a priori clinical experiences. In this article I discuss what I think are the strengths and weaknesses of current practice in the immobilization of children and attempt to find a scientifically based common ground that allows transport programs to provide more safe and consistent care.

The principal obstacle in changing current practice is the fact that the vast majority of children cared for and immobilized do not have spinal fractures or neurological injury.1 and 2 Safer cars, increased seat belt and helmet use, and organized early age safety education have all combined to decrease these injuries. This hampers changes in practice because many clinicians do not see complications from their current immobilization techniques. Simply put, poor or inadequate immobilization is not a problem in the uninjured child. The rarity of these injuries, coupled with their morbidity, make proper spinal immobilization vitally important. As stated, common clinical goals are an appropriate starting point in approaching the standardization of pediatric spinal immobilization.

Goals of spinal immobilization

The universally agreed-on goal of spinal immobilization is the prevention of neurological injury by pathological movement of injured vertebrae or vertebral components.3, 4, 5, 6, 7 and 8 What is less clear is what population requires this protection. Current triage protocols focus on a combination of assessment of the patient's mechanism of injury (MOI) and neurological/mental status.

Fortunately, prehospital and transport clinical decision making have some absolutes. A pediatric trauma patient who is unconscious, has an altered mental status (from injury or intoxicants), has a neurological deficit, or has spinal pain on initial examination requires spinal immobilization.3, 7, 8, 9, 10 and 11

If a trauma patient does not meet these criteria, the decision to immobilize is based on the patient's MOI. MOIs that predispose patients to spinal cord injury are listed in Table 1. Any child with a significant MOI and a distracting injury (ie, an obviously fractured extremity) requires spinal immobilization.

Table 1.

Mechanisms of Injuries Predisposing Children to Spinal Injury

Data from Sanders MJ, McKenna K.7

Literature has begun to challenge the need to immobilize any patient not meeting these criteria. Domeier et al10 and 11 demonstrated in a large multicenter trial that the triage application of the criteria just outlined captured the vast majority of spinal injuries.

The difficulty in extrapolating the adult literature to pediatric patient care is the questioned reliability of the child to contribute to the caregiver's assessment.

Obviously the preverbal child will not be able to assist, and many believe children younger than 12 years may be equally unreliable. Because of these factors, the child younger than 12 with a significant MOI should be provided with spinal immobilization (with medical control guidance) until radiographic or a more complete medical examination can be completed.

Any discussion on the benefits of spinal immobilization needs to be balanced with an understanding of potential complications that may be encountered. Spinal immobilization is uncomfortable, requires time to apply (which may delay transport), may impair ventilation, and has the potential to increase the risk of aspiration.12, 13, 14 and 15 Prolonged use may cause skin breakdown on points of pressure. These issues make the prudent application of spinal immobilization important in both preventing iatrogenic morbidity and providing safe and efficient transport.

Proper spinal immobilization of the injured child for transport should include the following:

1. A rigid, appropriately sized cervical collar. A well-placed collar should position the spine in a neutral position and control flexion and extension.

2. A hard backboard that supports the entire spine should be applied. Padding of the board will be necessary to provide neutral alignment in children and improve patient comfort without compromising cervical spine stability.6, 7 and 8

3. Lateral support (with commercial blocks, sandbags, or towel rolls) should be applied to the head to prevent rotation of the cervical spine as well as lateral bending. It also must provide support should the board need to be turned in the event of emesis.

4. Straps should be applied to the backboard to immobilize the patient (at the head, shoulders, pelvis, and knees) and protect spine stability when moving or turning the patient.

5. Tape or a strap also should be applied to the forehead to assist in keeping the head down in the anxious, agitated, or combative child. The use of tape or a strap across the chin is more controversial. Aggressive use of chin restraint often leads to unwanted cervical extension and may further inhibit mouth opening in the event of emesis. An appropriately sized cervical collar should prevent neck flexion, and a forehead strap in most cases should keep the child positioned. The benefit of chin restraint must always be weighed against possible complications.

6. The immobilization device should preferably not interfere with subsequent radiologic examination.

7. The immobilization should allow access to the patient for assessment and treatment.

An important and often overlooked facet of spinal immobilization in children, especially during transport, is that when correctly applied, it allows caregivers access to the patient without the need to alter or compromise the immobilization. Correctly applied spinal immobilization also should not need to be reinforced or changed on arrival to the emergency department. With this in mind, a discussion of current techniques and their relative strengths and shortcomings can be examined.

The long board/short board

The long/short spinal board is often overlooked in the immobilization of children. It is an excellent tool for many reasons. Nearly every prehospital provider has one readily available. Straps and tape are easily applied. Its size allows total patient access when the child is placed supine, and most are radiographically neutral. This board is also easily secured to ambulance or aircraft stretchers, increasing transport safety. The single daunting factor in the use of the spinal board is the appropriate use of padding to place the cervical spine in a neutral position (and to fill lateral space in the infant or small child).

Children up to approximately 8 years old have a proportionally larger head than body. This will cause neck flexion in the unsupported child. Thoracic support (with blankets or padding) is used to prevent cervical spine flexion. In addition, padding will increase patient comfort as well as ameliorate some conductive heat loss from the patient's skin contacting the cooler surface of the board.6 Figure 1 demonstrates the cervical flexion caused by occipital prominence in children of various ages.

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Figure 1. Cervical flexion caused by occipital prominence in children of various ages.

Another option that has gained increasing acceptance, especially in relation to spinal immobilization of the pediatric patient, is the use of vacuum splints. Such a device, when used in conjunction with a rigid board, may address the previously discussed issues of padding for patient comfort and support. The long/short board is easily turned in the event of emesis and is familiar to all emergency departments. Boards with metal components should be avoided when possible to prevent interference with radiologic examination.

The infant/toddler car seat

This form of immobilization, although commonly used and taught, may be the method with the most potential complications. The car seat is an excellent tool during extrication as it allows for rapid removal of the child from the vehicle.

Once removed from the vehicle, it is an extremely unreliable method of spinal immobilization. If the child is left upright in the seat, it demands that the potentially injured cervical spine support the weight of the head, a condition that we demand of no other trauma patient. An upright position also requires the thoracic and lumbar spine to support the weight of the body. If the car seat is placed in a supine position, the flexed lower extremities may apply pressure to the abdomen, potentially embarrassing respiratory effort in an age group that predominately uses their abdominal muscles to support respirations. Applying a cervical collar and placing posterior padding in a seated child requires extensive patient movement and has the potential to aggravate injuries.

Access to the patient is often limited, and the child will need to be re-immobilized on arrival to the emergency department to allow for radiologic/physical examination. I believe that the groups best suited for rapid and appropriate spinal immobilization are prehospital and transport crews. It is always in the best interest of children to have care provided by the most qualified caregiver. Recognizing this, it is important that paramedics and transport crews are taught and encouraged to properly remove a child from a car seat and provide effective spinal immobilization. I recognize the resistance to this well-entrenched practice. It is important to recall that clinical practice should be directed toward the appropriate treatment of the suspected but rare injury rather than to procedures presumed to be more expeditious.

The Kendrick extrication device

The Kendrick extrication device (KED) is another commonly used immobilization device that may present more potential complications than most providers acknowledge. Markenson et al.4 advocate the routine use of the KED for all pediatric patients, championing its availability, familiarity, and adaptability. The KED has significant limitations that I believe make it applicable in only a small number of injured children. As previously discussed, the knees of traumatically injured patients must be supported to prevent undue stress on the lumbar spine (a common site of pediatric spine injury). Allowing lower extremities to freely move or permitting the weight of the lower extremities to fall below the level of the pelvis places undue stress on the potentially injured thoracic/lumbar spine. These same considerations demand that adult patients be placed on a long board after extrication with the KED.7, 8, 13 and 16 Interestingly, Markenson et al.4 endorse the need for lower extremity support but offer illustrations of a child immobilized in a KED without fully supported lower extremities. Figure 2 illustrates this limitation of the KED with a volunteer 8-year-old. Additionally, the flexible nature of the KED, which makes it so helpful in extrication, restricts its usefulness in immobilization. Extremely small children do not have enough thoracic width to prevent lateral compression of the KED should it be needed to be turned in the event of emesis.

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Figure 2. Lack of lower extremity support with a Kendrick extrication device.

When turned on its side, the posterior surface of the KED may distort (bow out), compromising spinal immobilization. This limitation is illustrated in Figure 3. A small child immobilized in the KED requires not only posterior padding for neutral spine positioning but also lateral padding to fill space not occupied by the child (as is required on long/short backboards). This space may be filled by folding the edges of the KED or with towel or blankets. The diversity of size in the pediatric patient makes this practice time consuming and indiscriminate. Padding and rolling the edge of the KED may obscure the patient, hampering reassessment. Should access to the patient be required in transport, removal of this padding or lateral support may impair immobilization. Although I concur that the KED is readily available and certainly familiar, its limitations in all but a small percentage of children may outweigh its benefits.

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Figure 3. Distorted posterior surface of the Kendrick extrication device.

Age-appropriate cervical spine stabilization

The characteristics of the developing pediatric cervical spine necessitate appropriate immobilization. The underdeveloped supporting muscles, loose ligament structure, partially ossified vertebrae, and instability of the atlantooccipital joint increase the child's risk of serious cervical injury as a result of significant mechanism of injury.5 A properly fitting cervical collar is an important first step in adequate spinal immobilization.

A properly sized pediatric cervical collar must take into account several key anatomical differences. One of the most obvious differences is the child's larger head-to-torso ratio. This, combined with the increased range of motion seen in the pediatric cervical spine, may compromise the spine's ability to be maintained in a neutral position.16

The relative difference in neck length between the adult and child is another important consideration when immobilizing the pediatric cervical spine. The more acute angle between the occiput and shoulders, smaller chin-to-chest distance, and higher fulcrum of flexion seen especially in the infant and toddler age groups must be taken into account.17 Attempting to stabilize the cervical spine while failing to account for these significant differences can jeopardize appropriate airway alignment and thus the child's ability to breathe and ventilate.

The properly fitting pediatric cervical collar should provide appropriate occipital support, maintain adequate cervical spine and airway alignment, and provide sufficient lateral support.7, 8 and 16 The patient's chin should not overlap or sink into the chin well of the cervical collar. Again, the diversity of patient size can make placing an appropriately sized cervical collar a daunting task.

In the absence of an available properly fitting cervical collar, acceptable practice is to immobilize the child's spine to a rigid backboard in the standard fashion and using towel rolls (lateral support) and tapes or straps to stabilize the cervical spine.7 and 8 If a cervical collar is not used chin support (by tape or strap) is required to control flexion. When providing cervical support with lateral support/towel rolls, it is imperative to prevent pressure on the anterior neck, which may impede ventilation, respirations, or circulation.

A commercially available collar that takes into account the unique anatomical differences of the pediatric cervical spine is the Miami Jr (Jerome Medical, Moorestown, NJ) cervical collar (Figure 4). With four different sizes available, this product line includes the infant to preteen age range. Replaceable and washable padded inserts increase comfort. This is particularly important when the child will be in the collar for extended periods (typically 6 hours or more).17

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Figure 4. Miami Jr cervical collar.

Commercial devices

Most immobilization devices commonly available have some shortcomings. Recognizing this, several companies have produced pediatric-specific immobilization devices, eliminating many of the limitations of techniques previously discussed. They are adaptable to most children too small for adult devices and are easily secured for patient transport. The largest drawback to commercial devices is the initial cost. Budgetary constraints in programs that rarely care for children may make the purchase of these devices impractical. A device should be selected based on the previously stated criteria for proper pediatric spinal immobilization.

Of particular interest is a line of products developed by the Ferno Corporation. The Pedi-Pac (Calgary, Alberta) is simplistic, compact, functional, and most importantly provides access to the patient (Figure 5). Please note that the same company that manufactures the KED board recognizes the need for age-appropriate immobilization not addressed by the adult extrication device.

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Figure 5. The Pedi-Pac.

Particular to the infant age group is the Medkids (Ferno, Wilmington, OH) baby board. The device easily fastens to most stretchers and litter systems and helps maintain spinal column alignment with a self-contained pneumatic positioning device. It accommodates the wide range of thoracic elevation requirements without any extra padding and also provides easy access to the patient (Figure 6).

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Figure 6. Medkids Baby Board.

Conclusion

The spinal immobilization of children is challenging, often requiring ingenuity and improvisation to properly provide care. Keeping in mind the requirements for spinal immobilization, many options are available to transport crews. The limitations of current practices need to be recognized. Educating prehospital and transport crews on the proper extrication and immobilization of children is vitally important. The use of pediatric-specific commercial devices should be evaluated because they offer transport crews the fewest clinical limitations. Coordination with local medical control in developing policies for pediatric spinal immobilization is also important in this process.

References

1 MJ Hamilton and ST Myles, Pediatric spinal injury; Review of 174 hospital admissions, J Neurosurg 77 (1992), pp. 700–704. Abstract-EMBASE | Abstract-MEDLINE

2 MJ Hamilton and ST Myles, Pediatric spinal injuries: review of 61 deaths, J Neurosurg 77 (1992), pp. 705–708. Abstract-EMBASE | Abstract-MEDLINE

3 M Domeier, Indications for pre-hospital spinal immobilization, Prehosp Emerg Care 3 (1999), pp. 251–253.

4 D Markenson, G Foltin and M Tunik et al., The Kendrick extrication device used for pediatric spinal immobilization, Prehosp Emerg Care 3 (1999), pp. 66–69. Abstract-MEDLINE | Abstract-EMBASE

5 JA Nemeth, Case study: a new approach to stabilization of the cervical spine in infants. The Academy Today: Am Acad Orthotists ProsthetistsAvailable at http:/www.oandp.org/academytoday/2005apr/4.asp.

6 M Nypaver and D Treolar, Neutral cervical spine positioning in children, Ann Emerg Med 23 (1994), pp. 208–211. Abstract-EMBASE | Abstract-MEDLINE

7 In: MJ Sanders and K Mckenna, Editors, Mosby's Paramedic Textbook (2nd ed.), Mosby Publishing, St. Louis (2001).

8 US Department of Transportation. EMT basic: national standard curriculum. Washington, DC: National Highway Traffic Safety Administration.

9 RM Domeier, RW Evans, RA Swor, EJ Rivera-Rivera and SM Frederiksen, Prehospital clinical findings associated with spinal injury, Prehosp Emerg Care 1 (1997), pp. 11–15. Abstract-MEDLINE

10 RM Domeier, RW Evans, RA Swor, EJ Rivera-Rivera and SM Frederiksen, Prospective validation of out of hospital spinal clearance criteria: A preliminary report, Acad Emerg Med 4 (1997), pp. 643–646. Abstract-EMBASE | Abstract-MEDLINE

11 RM Domeier, RW Evans and RA Swor et al., The reliability of prehospital clinical evaluation for potential spinal injury is not affected by mechanism of injury, Prehosp Emerg Care 3 (1999), pp. 332–337. Abstract-EMBASE | Abstract-MEDLINE

12 D Bauer and R Kowalski, Effect of spinal immobilization devices on pulmonary function in the healthy nonsmoking man, Ann Emerg Med 17 (1988), pp. 915–918. Abstract

13 D Bauer and R Kowalski, The effect of spinal immobilization on healthy volunteers, Ann Emerg Med 23 (1994), pp. 48–51.

14 D Chan, RM Goldberg, J Mason and L Chan, Backboard versus mattress splint immobilization a comparison of symptoms generated, J Emerg Med 14 (1996), pp. 293–298. SummaryPlus | Full Text + Links | PDF (3266 K)

15 M Walsh, T Grant and S Mickey, Lung function compromised by spinal immobilization, Ann Emerg Med 19 (1990), pp. 615–616. Abstract

16 In: JE Tintinalli, GD Kelen and JS Stapczynski, Editors, Emergency Medicine: A Comprehensive Study Guide (6th ed.), McGraw-Hill Professional, New York (2003), pp. 1546–1547.

17 Jerome MedicalAvailable at http://www.jeromemedical.com/html/miami_jr.html.

1 Christopher Wagner, RN, CFRN, EMT-P, and Paul Mazurek, RN, BSN, CCRN, CEN, EMT-P, are flight nurse specialists with Survival Flight at the University of Michigan in Ann Arbor.

[stcommodore]

I don't think its really a respectful thing to go around calling myself or others names. Nor do I think it is fair to make asumptions on why I didn't reply. Did it ever come into your head that I may have a life outside this website and left to go join the real world? Myself and many others haven't been in the field for years and like everyone else we all learn something everyday. I understand the guidlines of my squad and will retract the comment about it being in the protocals. It looks like alot of good reading was posted and hopefully I'll get a chance to go through it all. So for future reference I will never be offended by being corrected on a point but think its really unprofessional to harp on someones error as you did.

[paramedicmike]

So for future reference I will never be offended by being corrected on a point but think its really unprofessional to harp on someones error as you did.

Dude! You flat out lied! And when you were called on it you continued with your story. Would you let it slide if someone lied to you?

Unbelievable.

[Ace844]

Dude! You flat out lied! And when you were called on it you continued with your story. Would you let it slide if someone lied to you?

Unbelievable.

{Said tongue in cheek in my worst DR Phil type PC whiny dribble voice}

"Paramedicmike,"

Don't you know know its not nice or PC, or POLITE to say to someone's face anymore that they lied, and it's obvious and we all know it!!! SHEESH, now his psychotherepy bills are going to be through the roof. We can't go around offending people who are willing to blatantly lie to us all, ya know!?!? I mean what is this world coming to? SIGH...SHRUG...

ACE844 8) 8)

[stcommodore]

Mabye you need to reread what a lie is. I was incorrect its like not I came out and said "I'm a doctor" that would be a lie. If I made something up to sound cool or appear better then someone else then that to would be lying. But by being wrong on a test does the teacher then say that you were lying?

[Ace844]

Does anyone else want here want to throw this guy a life jacket or help him out, or perhaps sell him one of the below...???? [marq=left:dc9091265b]***NOTE:when reading the picture please ignore the 'BITCH' comment...I don't know how to edit that out of the photo...my apologies if this offends someones senseabilities******[/marq:dc9091265b]

[stcommodore]

I was more then willing to drop it and move on. Obviously I was wrong in what I said before so it really doesn't do any good to stay stuck on the point now does it?

[Ace844]

"Stcommodore,"

While your perusing the threads and learning, here's something else for you to look at and compare with the literature...

Oh and by the way because your going to need it to prophalax the migraine your going to get.... have one or more of these to:

Now on to the charts:

[stcommodore]

thanks