Spinal Immobilization: Are we doing more harm than good ?

[Ace844]

This is indeed a fun debate with very intelligent views and opinions, however we are obligated to follow protocol. I hope medical directors follow this debate and perhaps change accordingly. The protocol I work under does allow me to clear spinal immobilization in the field. The following is are standing orders

Spinal Precautions

Full spinal immobilization should be considered for all non-ambulatory trauma patients who sustain a mechanism of injury with the potential for causing spinal injury and have one of these clinical findings.

a. spinal pain or tenderness

b. altered LOC or Hx of loss of consciousness

c. evidence of ETOH

d. significant distracting painful injuries (long bone fracture)

e. any abnormal neurological findings

f. extremes of age (young-old)

Patients who are or who have been ambulatory and meet the criteria above should be considered for the following spinal precautions

a. hard cervical collar: if complaining of neck pain or the above listed.

b. secure to stretcher if complaining of neck, thoracic, or lumbar pain or above listed.

Back boards may be used at any time if the attending ambulance personnel feel it is useful. If the patient is back boarded prior to the ambulance arrival, they should remain on the backboard.

A cervical collar should be used on all patients with suspected neck injury unless the time taken to apply endangers the safety of the employee.

medic 5587

STP

protocols are practice guidelines and minimums, not the end all be all last word...but alas lets try to keep this on topic..this has been discussed elsewhere here well the "protocol" bit anyway

[medic5587]

Anyone from an EMS system here that has a c-spine field clearance protocol? What have your experiences been so far?

I heard Central DuPage EMSS (half hour west of Chicago, busy urban-suburban system) has had a c-spine field clearance protocol in use for several years. Markers include mechanism, pain, neuromotor scoring, neuro (GCS) deficits, etc. It doesn't mean they escape spinal immobilization, it means they escape riding the backboard.

Dustdevil's point about a patient's post-accident frame of mind by the time a MD performs an ED c-spine clearance is rooted in absolute truth: they're just unwinding enough to finally focus on themselves (not their car, motorcycle, cellphone, purse, children, missed job interview, etc.).

I'd also like to hear how often anyone here still applies a KED for high speed trauma, or if anyone applies it regularly for MVC victims as part of policy/protocol.

_________________

E J C, nremtp/ccemtp

I was simply answering a question. Yes we have the protocal. Here are the guidlines.

The end!

[medik8]

Not frequently....but I DO use it... It IS protocol, but there again...sometimes I just "board". It really depends, and as long as the rationale seems to fit the scenario (???), it seems to fly. Don't usually get questioned for not using a KED; but moreso for the absence of a board (which I rarely do).

[vs-eh?]

Anyone from an EMS system here that has a c-spine field clearance protocol? What have your experiences been so far?

I heard Central DuPage EMSS (half hour west of Chicago, busy urban-suburban system) has had a c-spine field clearance protocol in use for several years. Markers include mechanism, pain, neuromotor scoring, neuro (GCS) deficits, etc. It doesn't mean they escape spinal immobilization, it means they escape riding the backboard.

Dustdevil's point about a patient's post-accident frame of mind by the time a MD performs an ED c-spine clearance is rooted in absolute truth: they're just unwinding enough to finally focus on themselves (not their car, motorcycle, cellphone, purse, children, missed job interview, etc.).

I'd also like to hear how often anyone here still applies a KED for high speed trauma, or if anyone applies it regularly for MVC victims as part of policy/protocol.

_________________

E J C, nremtp/ccemtp

I was simply answering a question. Yes we have the protocal. Here are the guidlines.

The end!

We don't have either a spinal "protocol" or a clearing "protocol". I am aware of the Canadian C-spine Clearance thing and yes I loosely use it at times but in the end I will repeat...

The assessment of whether or not to spinal immobilize a patient is basic, not complex. It isn't a chest pain or an NYD abdo call. It is based on clinical assessment and observation. And, in the end, if doubt remains? Then board them, just don't do it blindly because "protocol" says so.

How do you immobilize a patient without a backboard? Are you saying that if you think they really need immobilization they get a board and if not they get.....a scoop? Collar only and telling them not to move? I don't follow...If I choose to immobilize a patient they get it all - board, straps, head rolls and collar. None of this BS collar only garbage, I always laugh when I see patients (thankfully it's rare) come in like this. And yes I know that patients in hospital this is often done, but that is the docs decision.

KED - Only used it twice and funny enough it was the same week :? First was a roll over and my partner (who FYI hadn't attended an emerg call in years) said that we should use a KED, I was like ummmmmm, but whatever. The other one was a highway extrication where the roof was cut of, I suggested a KED to pull the patient out (only because of the call a few days prior) and we did it. Worked well. But here they are only used for ped immobilization where boarding the kid isn't feasible. It limits assessment too much and is more trouble than its worth.

[EMS49393]

My service uses the KED for stable, otherwise uninjured appearing patients in MVC's with little significant MOI, yet complaining of back and/or neck discomfort. It takes less then 3 minutes to apply one if you're proficient at it and we physically assess our patients before we place them in the KED to remove them from the vehicle. They go from assessment, to KED to long board onto stretcher. The KED keeps the spine in line much better then collaring someone and yanking them out of a car. Again, let me restate, we use it on STABLE patients with no significant MOI yet still complaining of back or neck pain. If things begin to change, they're on a long board and we can always undo the three straps to KED to access that region on the patient.

We're looking into changing from the KED to the speedboard. If you haven't seen one, check into it. There are many reasons why it's a fantastic peice of equipment.

Just a little FYI, those hook straps on the KED aren't load bearing.

[island emt]

State of Maine has been using a field spinal clearance protocol since 1994 . the latest version was enacted in 2002.

www.state.me.us/dps/ems/docs/spinal.html

The protocol was developed over several years after the NEXUS study which found that prehospital professionals were able to appropriately assess the need for full immobilization + were able to rule out the probability of spinal injury as good as or better than many ER staffs . the algorithm is to be followed in assessing motor neuro abilities + disabilities , pain on palpation + exam of the spine. distracting major injuries , reliability ie a+o x 4 no alcohol or drug impairment , no other fatalities in vehicle, The first version used mechanism of injury as a determining factor, but was removed in the current version. please take the time to read the documentation available on the state web link i provided as it will explain answers to a lot of the questions raised in this thread. it includes a lot of history on this protocol and the studies used to develop it. Dr John Burton , an ER doc @ Maine Medical Center + former State Medical director was instrumental in the implementation of this protocol.

[Ridryder 911]

Our protocol is similar to Vs-Eh. We observe MOI, and neck pain. If no parathesia, clearance of similar to NEXUS is determined. We will never be faulted for immobilization. As time has progressed, we are less and less back boarding those that do not have MOI or potential neck injuries. I am finally breaking most of the crews habit that every fall does not need LSB & CID, if it quite apparent there was no cervical pain or potential injuries.

I do look for things to change.. and here is why. Within the next 3-5 years they are expecting triple the number of ER patients nationwide.. so you can see the wait and delay before clearance occurs. Either they will educate ER nurses to manually clear non-spinal injuries or enforce and educate EMS personal when it is truly essential and worthy.

Be safe,

R/R 911

[Ace844]

Since we have been debating the various methods of c-spine and LSB/spinal immoboilization here for some time, and this is the most recent related discussion I have decided to post this study here for your info. Any one have any thoughts or opinions???

Comparison of the Ferno Scoop Stretcher with the Long Backboard for Spinal Immobilization

Julie M. Krell A1, A4, Matthew S. McCoy A1, Patrick J. Sparto A2, Gretchen L. Fisher A3, Walt A. Stoy A3, David P. Hostler A1

A1 Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania

A2 Department of Physical Therapy, University of Pittsburgh, Pittsburgh, Pennsylvania

A3 Center for Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania

A4 Long's Peak Emergency Physicians, Longmont United Hospital Emergency Department, Longmont, Colorado

Abstract:

Objectives. Spinal immobilization is essential in reducing risk of further spinal injuries in trauma patients. The authors compared the traditional long backboard (LBB) with the Ferno Scoop Stretcher (FSS) (Model 65-EXL). They hypothesized no difference in movement during application and immobilization between the FSS and the LBB. Methods. Thirty-one adult subjects had electromagnetic sensors secured over the nasion (forehead) and the C3 and T12 spinous processes and were placed in a rigid cervical collar, with movement recorded by a goniometer (a motion analysis system). Subjects were tested on both the FSS and the LBB. The sagittal flexion, lateral flexion, and axial rotation were recorded during each of four phases: 1) baseline, 2) application (logroll onto the LBB or placement of the FSS around the patient), 3) secured logroll, and 4) lifting. Comfort and perceived security also were assessed on a visual analog scale. Results. There was approximately 6–8 degrees greater motion in the sagittal, lateral, and axial planes during the application of the LBB compared with the FSS (both p < 0.001). No difference was found during a secured logroll maneuver. The FSS induced more sagittal flexion during the lift than the LBB (p < 0.001). The FSS demonstrated superior comfort and perceived security. Conclusion. The FSS caused significantly less movement on application and increased comfort levels. Decreased movement using the FSS may reduce the risk of further spinal cord injury.

Hope this helps,

ACE844

[Dustdevil]

Saw that one awhile back. Definitely no surprises for me. Anybody who has used both devices should know that. Glad to see somebody validated it scientifically though. I'd like to see everybody scooped. Plop them onto the ER gurney and take your scoop with you. That way the patient doesn't remain on a hard board, you don't lose your equipment at the ER, and the immobilization burden is on the ER doc, where it belongs.

[PRPGfirerescuetech]

Standing take down for a standing patient with head and neck pain.

With a scoop...how?