Field Clearance of C-Spine; Help me if you can

[paramaximus]

While the EMS service I work for is fairly progressive compared to many, one area we are behind in is field clearance of c-spine. Hence the smallest "crash" or fall brings about a needless cocktail of hard spine boards, straps, clips, head blocks, back pain... and the patient doesn't like it either.

So... do any of you out there have a specific protocol you utilize for field clearance of the spine? I would imagine mechanism would be a large part of it, what else?

I would love to hear from you, if you'd rather... send me your protocol via the email address provided. I would love to join the 50 plus percent of services (according to JEMS) that do this.

Thanks,

paramaximus

[CBEMT]

Nobody "clears" c-spine in the field. They may have a Selective Spinal Immobilization protocol, but walking around claiming you "cleared" the patient's cspine is asking for trouble.

[croaker260]

Well, I cant agree more regarding the use fo the term "clearing C-Spine". technically, C-spine can only be cleared with Xrays or increasingly CT, something more and more doctors are becoming comfortable releasing patients from the ER with out (for many reasons, economic and medical both).

Now at this point you are saying WAIT, what do you mean they arnt getting Xrays? What do they use to determine who gets them and who doesnt? the same basic criteria that a good SSI (selective spinal immobilization) protocol uses to determine if someone is boarded to begin with. Its a subtle point, but an important one that clearly reflects the thought process needed for this: We do not "Clear" anyone in the field. We chose who would benefit from immobilization just like ANY OTHER treatment.

We selectively apply the board to patients who need it, just like we give NTG to people who need it, not everyone who has chest pain (trauma, etc). Nor do we splint everyone who has pain in their leg…I could go on and on and on…but you get the point.

Just to be sure you get the point of the "theory" behind SSI, so you procede in your protocol development correctly, let me repeat:

You should not look at it as if we are deciding NOT to do a normal thing…and act of omission.

We are in fact determining if someone would benefit from a treatment…the board, like oxygen, NTG, and morphine…is a treatment.

And it is a treatment with VERY REAL complications, just as it has some limited benefits.

So we look at the patient…we ASSESS them, and the MOI, and it is a DETAILED AND FULL ASSESSSMENT, based on a GOOD CLINICAL KNOWLEDGE BASE, and TRAINING. Then we decide if a treatment would be beneficial and if the potential benefit for THAT PATIENT would outweigh the RISKS/COMPLICATIONS. Then we SELECTIVELY APPLY THAT TREATMENT. It’s “SELECTIVE SPINAL IMMOBILIZATION” of the whole spine, not CLEARING the C-SPINE.

My point is that we should look at boarding like every other treatment, and do it based on clinical assessments.We are taught to always "rule in" before we "rule out" immobilization as an option. I view this..spinal immobilization, as a treatment and intervention like any other...good for some, harmful for others. And make no mistake, It can be harmful in select patients. (pain, pressure sores, neuropathic injury, respiratory issues from being prone). Kinda like chest pain, you "rule in" the potential for cardiac, then when you find out it is chest wall pain, pleuratic, and so on...you dont give NTG do you? Heck no..you make an assessment and make a CLINICALLY based decision.

It is important also to note the start of the use of this procedure/concept was based on a 15 year review of spinal cord injury research.

That research found that "our patients are not suffering from “occult spinal injuries,” they are suffering from lack of assessment and lack of a prehospital standard of care for evaluating and deciding risk for spine injury.

In fact, No assessment criteria are absolute, but one study of 34,069 patients concluded that the accuracy of its assessment criteria would result in less than one missed injury for every 4,000 patients. Now if I recall, that was for Fractures of spine, an even smaller number would have been missed for cord patients. I would personally go so far to say that since we see an increase of immobilization of patients in some sub catagories, that not having such a protocol may increase your risk for missing a true injury.

Even if you , after doing the research, would still subscribe to the "board 'em all, let the X-ray sort them out" school, I would still recommend you use the protocols and articles out there to improve both your assessment focus and your documentation of immobilized patients.

What about MOI? As one study stated, "MOI has not been shown to be an independent predictor of injury or the lack thereof." It is , however a good gauge for when assessment of need for immobilization shoul occur, a subtle but important difference. So just to be clear: MOI is important, but of limited value to NO value when that is ALL you use, to rule in , or to rule out. Your protocol MUST have assessemnt (subjective and objective) factors in it. And let me say this again too: IF YOU CANT GET A GOOD ASSESSMENT, THEN YOU SHOULD BOARD.

Remember that there are complications of use of a spine board, it is not as benign as we are taught in EMT/medic school. The use of a systematic assessment based decision making process can safely determine who needs to be boarded and who doesn't. Remember that in every protocol the medic can always chose to board the patient based on gut feeling. In fact, most services report they board MORE patients under the protocol than when they "winged it".

The keys to successful implementation is :

1- Educational preparation. A training program that discusses the WHY's behind boarding, not boarding, the decision process, and the anatomy involved. If your service is not willing to do the training , the rest will fail.

2- Medical oversight, review, and retraining.

3- adhearance to the protocol. In our service we had a missed (stable) Fx with out cord involvement. On review it was not the protocols fault, the EMT did not follow the protocol, and just winged it. If you follow the protocol, you will pick up the information you need to make the correct decision.

Some more thoughts...

- Most missed injuries result from inability to get a good assessment due to altered LOC, or distracting injury. That’s why if you cant get a good assessment you board them.

- In our protocol, major trauma or high mech of injury gets boarded. In addition over 70, under 8 (SCIWRA is the reason), and osteoporosis are also inclusionary criteria. So the "a guy who falls on his head off a fast moving vehicle that looks fine"...would probably get boarded regardless. This is for those "gray area patients" who probably don’t have injury, but lets have a systematic approach to the assessment and decision making process. An approach that is based on medical evidence. Why? Because boards hurt patients too.

- There is some debate on if this should be an EMT-basic level skill, based on initial education and cont ed on the A & P behind this. In my observations, some EMT-s properly trained in my system seem to be some of the most rigid in adherence to the protocol...but again this is after orientation and then they are all trained by Medic FTO's, and only work with a medic. Those new reserves in my system (straight out of school) seem to have problems with this.

- While it is tempting to focus on the cervical spine, it is important to assess and clear the entire spinal column. Any good protocol and good clinician addresses this. It is in my experience, more common to see a Fx (however stable) in the lumbar region, but that is a commonality of MOI issue.

Some reading for you:

An excellent article by an ER doc on the subject. The article is from 2004, and I believe that sense the article was posted the protocol has been approved in most of his area of practice. The article is so good it is mandatory reading for our yearly SSI test.

http://www.sehsc.org/news/cspine.htm

Here is our SSI protocol:

http://www.adaweb.net/departments/paramedics/swo/1y.pdf

Here are our SWO's in general:

http://www.adaweb.net/departments/paramedics/swo2006.asp

More Reading:

~ Sahni R, Mengazzi JJ, Mosesso VN Jr. Paramedic evaluation of clinical indicators of cervical spinal injury. Prehosp Emerg Care 1(1):16–18, Jan–Mar 1997.

~ Cone DC, Wydro GC, Mininger CM. Current practice in clinical cervical spinal clearance: Implication for EMS. Prehosp Emerg Care 3(1):42–46, Jan–Mar 1999.

AANS and CONS published a position paper at http://www.spineuniverse.com/pdf/traumaguide/1.pdf and it has lots of citations.

~ Domeier RM: "Position Paper, National Association of EMS Physicians: Indications for prehospital spinal immobilization," Prehospital Emergency Care. 3(3):251-253, 1999

~ Domeier RM, Evans RW, Swor RA, et al: "Prehospital clinical findings associated with spinal injury," Prehospital Emergency Care. 111-15, 1997

~ Goldber W, et al: "Distribution and patterns of blunt traumatic cervical spine injury." Annals of Emergency Medicine. 38:17-21, 2001

~ Hendey GW, et al: "Spinal Cord Injury without Radiographic Abnormality: Results of the National Emergency X-Radiography Utilization Study in Blunt Cervical Trauma." Journal of Trauma. 53(1):1-4, 2002

~ Hoffman JR, Wolfson AB, Todd K, Mower WR: "Selective cervical spine radiography in blunt trauma: methodology of the National Emergency X-Radiography Utilization Study (NEXUS)." Annals of Emergency Medicine. 32(4):461-9, 1998

~ Holmes JF, et al: "Epidemiology of thoracolumbar spine injury in blunt trauma." Academic Emergency Medicine. 8(9):866-72, 2001

~ Panacek EA, et al: "Test performance of the individual NEXUS low-risk clinical screening criteria for cervical spine injury." Annals of Emergency Medicine. 38(1):22-5, 2001

~ Stroh G, Braude D: "Can an out-of-hospital cervical spine clearance protocol identify all patients with injuries? An argument for selective immobilization." Annals of Emergency Medicine. 37(6)6098-615, 2001

~ Ullrich A, et al: "Distracting painful injuries associated with cervical spinal injuries in blunt trauma." Academic Emergency Medicine. 8(1):25-9, 2001

~ Viccellio P, et al: "A prospective multicenter study of cervical spine injury in children." Pediatrics. 108(2):E20, 2001

[AnthonyM83]

Those protocols coincide with what I was taught as an EMT (not a significant MOI, A/O, no pain, no visible injury, no distracting injuries, not stressed/anxious) ... though in the field all the medics seem to cspine for everything.

Even the ones who do take the time to do a good assessment will cspine if there's any non-midline neck OR back pain (even from less than 5MPH accident, no vehicle damage), seatbelt use. I'm too new to decide if that's valid or not....what's the rate of neck fx in low speed accidents from non-midline neck/back pain? If it's 1 in 10,000 is that chance low enough? We go on accidents almost everyday...0 to 5 of them, usually.

I don't have a set opinion...just looking for input. I just know what makes intuitive logical sense to me, but only based on the limited info I have.

[zippyRN]

a lot of places start from NEXUS criteria or increasingly the Canadian C-spine guidelines for choosing whether to immobilise or not - it's in JRCALC v4 (which is directly relevant for us rightpondians) the question is - it is geneuinely a case of 'clearing the C-spine' depends on a number of factors -is this patient ever going to get Irradiated for it? quite possibly not if they have no distracting injury as NP/Doc in the ED is going to use the exact same rules to rule in /rule out ...

for the interest of the leftpondians, antipodeans and anyone else the JRCALC guidelines can be found at

http://www2.warwick.ac.uk/fac/med/research...006/guidelines/

http://www2.warwick.ac.uk/fac/med/research...trauma_2006.pdf

[paramaximus]

Thank you for the info thus far. While yes, I did say "Clearance of C-spine" I was under no delusions that we actually clear the cervical spine. Thank you for pointing out my poor choice of words. I suppose it's one of those things like RSI, people in the know realize it isn't Rapid Sequence Intubation but rather Induction.

Mistakenly spoken,

paramaximus

[ERDoc]

Check out the scenario on the 9y/o girl that was thrown off of an ATV. I posted the NEXUS criteria and a link to the CCS rules (as well as a study comparing the 2 sets).

[ccmedoc]

I agree with "selective immobilization" as opposed to mandatory immobilization regardless. Long back boards have been implicated in skin breakdown on bony prominences, such as the occiput. Long back boarding improperly can also exacerbate a previously occult injury that would not be as bad without the immobilization. sufficient padding and proper technique is necessary and I can say I haven't seen either more than I care to say. As for simply a c-collar, It may be prudent even without midline tenderness with questionable MOI due to a condition known as SCIWORA syndrome. This can pose a problem in both adults and children and may not even show on rad studies or films. Although the NEXUS criteria appears to be valid and good guidelines, they can be, as noted earlier rather cryptic.

That being said, I do not believe that all individuals need to be backboarded simply due to MOI. I have read studies(Have to track them down) that indicate the average backboard time from initial placement through clearance in the ED as upwards of 70 minutes, more than enough time for skin breakdown to begin on healthy adults, let alone the elderly and child. I know this was an older study and have seen time drop dramatically around my neck of the woods, so if this is not the case in your area great!. A thorough assessment, good instincts, and experience do well in situations such as these.

http://www.ijppediatricsindia.org/article....31;aulast=Kalra

[Dustdevil]

I agree with "selective immobilization" as opposed to mandatory immobilization regardless. Long back boards have been implicated in skin breakdown on bony prominences, such as the occiput.

That whole theory is a bunch of mullarkey. It's about as valid as the firemonkey committee's "evidence" that fire-based EMS is the best way to go. My challenge still stands to anybody who can show me a documented case of somebody developing a decubitus ulcer or other treatable "skin breakdown" from a trip to the ER on a backboard. Now, if the ER is leaving them on that board for hours upon hours, that's a separate issue that has no application to EMS.

As for simply a c-collar, It may be prudent even without midline tenderness with questionable MOI due to a condition known as SCIWORA syndrome. This can pose a problem in both adults and children and may not even show on rad studies or films.

What possible relevancy does SCIWORA have to immobilisation assessment in field EMS? And why would the consideration of SCIWORA lead anybody to believe that putting a c-collar on a patient, but leaving them otherwise non-immobilised was an acceptable thing to do?

[ERDoc]

As for simply a c-collar, It may be prudent even without midline tenderness with questionable MOI due to a condition known as SCIWORA syndrome. This can pose a problem in both adults and children and may not even show on rad studies or films.

If you are going to put a collar on someone, you should have them on a board. As Dust said, there have been no studies that show a ride in an ambulance on a backboard cause decubs, but there also no studies showing that it doesn't. There is simply a lack of studies. If they get to the ER and are left on the board for some time, then yes they may develop them (this has been documented). That's why the pt should be taken off the board as soon as they get to the ER. As for SCIWORA, they should be boarded and collared. Pts with SCIWORA have a neurologic deficit of some kind so. Based on both c-spine rules, they should be boarded and collared. It doesn't matter if they have midline tenderness or not. This is usually a problem with kids (very rare in adults) and as the name implies there will be no abnormalities seem on radiologic imaging.